Name
*
First Name
Last Name
Address
*
Address
Address Line 2
City
State
Zip Code
Email
Phone
*
Please enter a valid phone number.
Date of Birth
*
/
Month
/
Day
Year
Must be 50+ years old to become a member
Wedding Anniversary (Living Spouse)
/
Month
/
Day
Year
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Waiver and Release of Liability
I understand that the activities, services, trips, and events offered by the Parker Senior Center (PSC) may have an element of hazard or inherent danger, and further may be an extreme test of a person’s physical and mental abilities. I understand that my participation in such activities, services, trips and events can cause serious injury, potential death, and property damage. I understand participating in activities and trips while in a wheelchair may present special hazards, inherent danger, and be an extreme test of physical abilities. On behalf of myself, my executors, administrators, heirs, next of kin, successors and assigns, I hereby waive, release, and discharge the PSC, its officers, directors, employees, and volunteers from any and all claims, liabilities, losses, costs, or expenses, for death, personal injury, or damages of any kind that I may incur while participating in PSC activities, services, trips and events, whether such losses, damages or injuries are a result of negligence of PSC, its officers, directors, employees, and volunteers except for loss, damage, or injury which is the result of gross negligence and/or wanton misconduct of PSC, its officers, directors, employees, and volunteers. I agree to indemnify and hold harmless PSC, its officers, directors, employees, and volunteers from any claims made or liabilities assessed against them as a result of my actions, or any action taken on my behalf. In consideration of the rights and privileges granted to me by my involvement with the PSC, I certify that I have read and understand this WAIVER AND RELEASE OF LIABILITY and, by clicking the box below, hereby acknowledge that I am signing voluntarily. I also understand and agree that my photograph may be taken while participating in PSC activities, services, trips and events and such photograph may be used in publications and for promotional purposes and I will not be compensated.
Waiver and Release of Liability Agreement
*
I agree to the Waiver and Release of Liability.
Signature
*
Are you interested in becoming a volunteer?
*
Yes
No
Would you like to sponsor a membership for someone in need?
*
Yes
No
Select the number of annual memberships you'd like to sponsor:
Please Select
1 - $100
2 - $200
3 - $300
4 - $400
5 - $500
6 - $600
7 - $700
8 - $800
9 - $900
10 - $1000
Would you like to make a donation to Parker Senior Center?
*
Yes
No
Select a donation amount:
Please Select
$10
$25
$50
$100
$250
$500
$1000
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Yearly Billing
Membership Billing (if selected, sponsorships and donations added to first payment)
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( X )
Annual Billing ($100 Billed Yearly)
USD
for the
first year
then,
$
100
for each
year
Email
Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit & Pay
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