GenesisHOPE Adult Program Registration

GenesisHOPE Adult Program Registration Form

Genesis Harbor of Opportunities Promoting Excellence (GenesisHOPE) Community Development Corporation is a 501(c)(3) tax exempt MI charitable corporation founded in 2008 by Genesis Lutheran Church. Our mission is to meet the needs of the people, and then community, to eliminate poverty, blight and powerlessness by improve the quality of life for those living and working in Islandview Village.We are excited to work with you for committing to our various health-oriented programs and services! By registering for one of our programs or services, You are agreeing that GenesisHOPE can file your information from the form below, and understand this will be completely confidential from outside parties not aligned with GenesisHOPE.
Enrollment Date (Today's Date)*

MonthDayYear
Today's Date
Direct Education Program *
Participant's First Name *
First Name
Participant's Last Name *
Last Name
Participant's E-mail*
If Applicable
Participant's Phone Number*

Area CodePhone Number
Address*
Street Address
City*
City
State*
State / Province
Area Code*
Zip /Postal Code
Participant's Date of Birth*
MM/DD/YYYY
Participant's Gender*
Are you of Hispanic Origin?*
Participant's Race and Ethnicity*
Will you need Groceries?
Ingredients are provided for The Learning Kitchen participants only.
Are you able to pick up groceries from a disclosed location?
Grocery pick ups are coordinated with your direct educator. All pickups will be at Genesis Lutheran Church at 7200 Mack Ave, Detroit, MI 48214
Dietary Restriction*
(Ex: No Soy, Lactose Intolerance, No Sugar, N/A)
Allergies*
(Ex: Peanuts, Egg, Shellfish, N/A)
Hypertension*
Has a licensed doctor diagnosed the participant with hypertension or having a history of related symptoms?
Diabetes*
Has a licensed doctor diagnosed the participant with diabetes or having history of related symptoms?
Heart Disease*
Has a licensed doctor diagnosed the participant with heart disease or having a history of related symptoms?
Emergency Contact Name *

First NameLast Name
Emergency Contact Phone Number *

Area CodePhone Number
Consent and Release of Information: I hereby authorize GenesisHOPE and its successors to share information regarding my participation in all programs, including pre- and post-survey information and other information collected as a participant in adult programming offered by GenesisHOPE and its partners.

Media Release: I grant to GenesisHOPE, its representatives and employees the right to take photographs and video of myself in connection with my participation in programs offered by GenesisHOPE. I authorize GenesisHOPE, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that GenesisHOPE may use such photographs and/or video with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Release of Liability Waiver: I hereby release and forever discharge and hold harmless GenesisHOPE and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from participation in any program offered by GenesisHOPE. I understand that by signing I discharges GenesisHOPE from any liability or claim that may arise with respect to any bodily injury, personal injury, illness, death, or property damage resulting from participation in programs provided by GenesisHOPE, whether caused by the negligence of GenesisHOPE or its officers, directors, employees, or agents or otherwise. I understand that GenesisHOPE does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness.
Participant Signature*

Clear
Should be Empty:

GenesisHOPE Adult Program Registration Form