City of Byron - Senior Center Application

Name*

First NameLast Name

Email*

example@example.com

Date of Birth:*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone:*

Please enter a valid phone number.

Cell Phone:*

Please enter a valid phone number.

Check One:*

MaleFemale

Do you live alone?*

YesNo

Do You Drive?*

YesNo

Are you a veteran?*

YesNo

Hobbies/Interests:*

Emergency Contact Name: *

Relationship:*

Phone Number*

Please enter a valid phone number.

Phone Number

Please enter a valid phone number.

Emergency Contact Name 2: *

Relationship:*

Phone Number*

Please enter a valid phone number.

Phone Number

Please enter a valid phone number.

Hearing Aid?*

YesNo

Glasses?*

YesNo

Cataracts?*

YesNo

Dentures?*

YesNo

Walker! Cane?*

YesNo

Wheelchair?*

YesNo

Primary Doctor:*

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Participant Liability Waiver and Hold Harmless Agreement:

Please read this form carefully and be aware that by registering for and/or participating in programs sponsored by Middle Georgia Community Action Agency, Inc. and the

Senior Center, you will be waiving your rights to all claims for injuries you might sustain arising out of participation, and you will be required to indemnify, hold harmless and defend Middle Georgia Community Action Agency, Inc. for any claims arising out of participation in Senior Center activities.

Risk of Injury: As a participant in Senior Center activities, I recognize and acknowledge that there are certain risks of physical injury, including but not limited to death, and I agree to assume the full risk of injuries, including death, damages, or loss which | may sustain as a result of participating in any and all activities associated with participation.

Waiver of Injury Claims: I agree to waive and relinquish any and all claims | may have arising out of, connected with, or in any way associated with the activities of the Senior Center.

Release from Liability: I do hereby fully release and discharge Middle Georgia Community Action Agency, Inc. and its officers, agents, and employees from any and all claims from injuries, including death, damage, or loss which I may have or which may occur on account of participation in Senior Center activities.

Indemnity and Defense: I further agree to indemnify, hold harmless and defend Middle Georgia Community Action Agency, Inc. and its officers, agents, and employees from any and all claims from injuries, including death, damages, and losses sustained by me and arising out of, connected with, or in any way associated with the activities of the Senior Center.

| have read fully and understand and agree to the above-stated conditions of Senior Center membership.

In the event of any emergency, | authorize Middle Georgia Community Action Agency, Inc. to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed reasonable and necessary for my immediate care and agree that | will be responsible for payment of any and all medical services rendered to me.

I have read and fully understand and agree to the above-stated conditions of membership to the Type a label* membership to the Senior Center.
In the event of any emergency, I authorize Middle Georgia Community Action Agency, Inc. to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed reasonable and necessary for my
immediate care and agree that I will be responsible for payment of any and all medical services rendered to me.
I have read and fully understand and agree to the above-stated conditions of membership to the Type a label* Senior Center.

Client Signature:*

Date*

Date

Please verify that you are human*

Senior Center Membership Application

Emergency Contact Information: (Please List 2)

Medical Information: (Please check all that apply)