Participation Form

SENIOR SOCIAL GATHERING

1102 E. 30th St.Indianapolis IN 46205 ● 317.998.0065 ● consistentcaretransit@gmail.com
Adult Day

Wednesday through Friday

Every other Saturday

10:00A.M.-2:00P.M.

Registration Required for Transportation
Contact*

First NameLast Name
Contact Phone*

Work #Cell #
Address*

Address

Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Best Point of Contact*

EmailTextCall
Liability Release:

By signing this form, I hereby release Consistent Care Transit LLC DBA SENIOR SOCIAL GATHERING, any affiliates, volunteers, and any other entity connected with the facilitation or representation of Consistent Care Transit LLC for any and all known or unknown damages, injuries, losses, and/or claims, that may be suffered by participant or his/her property during the participation of the said activity/program/event.
Signature*
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