Memory Cafe Registration

Registration

Join us the first and third Fridays of the month, 10:00 - 11:30 AM in the Parish Hall
Registration Type*
Participant's Name*

First NameLast Name
Care Giver's Name*

First NameLast Name
Volunteer's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Is there anything we should know about the participant? (allergies, disabilities, etc.) Special needs or special requests?
Photo Release

I grant to Saint Matthew’s Episcopal Church, the right to take photographs in connection with the above-identified event. I authorize Saint Matthew’s Episcopal Church to use and publish the same in print and/or electronically. I agree that Saint Matthew’s Episcopal Church may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
I accept terms of photo release:*

YesNo
Health Policy

For the health and safety others, please keep stay home if exhibiting any of the following symptoms in the last 24 hours:
- A known or suspected infectious illness
- A fever of 100.0 F within the past 24 hours
- Nausea, vomiting, diarrhea, or feeling unwell
- Cough, sore throat, croup (except in the case of allergy)
- Colored runny nose
- Common cold
- Contagious skin rash
- Pink eye
- Lice
- Impetigo (infected wounds), boils, ringworm
- Use of antibiotics for 24 hours or less
I acknowledge I have received and read the Health Policy*

Yes
I acknowledge and understand that a caregiver must accompany the participant.*

Yes
Signature

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Registration

Photo Release