Thank you for you Payment, here are the last few steps to complete your application Thank you for you Payment! Here are the last few steps to complete your application: Emergency Contact Information(required) Medical Information(required) Physician Name and Phone number Allergies Special Assistance Needed (required) Please Choose Yes No Adaptive equipment/procedures needed to participate Glasses Hearing Aid Both Glasses and Hearing Aid Walker Wheelchair Other None Hospital Preference Disabled(required) Choose an option Yes No High Nutritional Risk(required) Please choose an option Yes No Live Alone(required) Choose an option Yes No Race(required) African American Asian American Hispanic American/Indian Caucasian Other Participation Policy and Waiver Consent Individuals wishing to participate in programs held by the West Chester Area Senior Center (the Center) should meet the following criteria to be considered appropriate for service provision: Be able to feed and toilet themselves independently Be able to ambulate safely Be oriented to their current surroundings Be able to clearly speak and socialize with others Behave in a non-aggressive and non-disruptive manner Desire to participate in a program or activity that is appropriate for them A complete copy of the participation guidelines and policies will be made available upon request by a participant or participant’s family member. Persons not meeting these criteria are welcome only if escorted by a responsible person at all times. This is required for the well being of all participants and staff participating in Center activities on or off the premises. The Center is not responsible for monitoring the activities of anyone visiting and/or participating in services or programs on or off the premises. Staff has the authority to make final decisions in all cases as to who is appropriate for participation in activities of the Center. I wish to take part in one or more events of the West Chester Area Senior Center and, to the best of my knowledge, information and belief, have no physical restraints which would prohibit my participation in the events. In consideration of my application for participation being accepted, I being legally bound, do hereby for myself, my heirs, my executors and administrators, waive and release any and all rights I may have against the Center, its directors, officers, agents, staff (paid or volunteer) and any other co-sponsoring organizations for any and all injuries, claims, damages or causes of action, suffered by me during my participation in the events of the Center. The Center has my permission to have a physician attend me if it is deemed necessary for my health, welfare and safety. I attest and verify that I am in sufficiently good health for each activity, and my physical condition has been verified by a licensed physician. I have read and understand the participation guidelines policy of the Center. I understand that during the course of a class, activity or program at the center my photo or video may be taken by a representative of or for the Center. I release the center to use this photo or video for the purpose of advertisement as the center deems appropriate. I read and Participation Policy and Waiver Concent(required) Yes No Please check box for online signature Submit Δ Share this:FacebookLinkedInEmailPrintMoreRedditTwitterTumblrPinterestPocket
