Class Registration Form Step 1 of 2 50% Registration FormPlease complete the following information. YOUR PERSONAL INFORMATION WILL NOT BE SHARED WITH ANY OTHER PARTY. ✱ Indicates REQUIRED field. Personal Information✱ First Name* ✱ Last Name* Mr. Mrs. Ms. Other please enter your title here ✱ Address: (include all information, including apartment number, if applicable)* ✱ City* ✱ State* ZIP ✱ Birthdate* MM slash DD slash YYYY Cell Phone✱ Home Phone*E-mail Address Marital StatusMarital StatusMarriedSingleWidowedDivorcedGenderGenderMaleFemaleDecline to StateLanguage Preference Do you live alone?Do you live alone?YesNoAre you a veteran?Are you a veteran?YesNoMilitary Branch Emergency Contact Information✱ Name* ✱ Relationship* Cell Phone✱ Home Phone*Work Phone Ethnicity African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White Hispanic or Latino Decline to State ✱ Signature:* ✱ Date:* Registration Form RecordingsThe SCV Senior Center photographs, videos, and audio records classes, programs and events of the SCV Senior Center. I understand that these may be used for reproduction of advertising, trade, display, exhibitions, or editorial use. Examples of these publications may include but are not limited to newsletters, brochures, reports, websites, slideshows, Power Point presentations, program photo albums, and/or audio-visual public service announcements. No media shall be used for exploitation or promotion of activities unrelated to the SCV Senior Center.✱ Enter Your Initials* ReleaseI understand and agree that the information contained on this form may be released for statistical purposes, and I agree to the release of information for that limited purposed only. I understand that any release of information in identifiable form must be accompanied by a signed consent form and that the information will not be used as an eligibility determination or effect participation as a recipient unless a law has specifically restricted program participation.✱ Enter Your Initials* THE SCV SENIOR CENTER WAIVER AND CONSENT AGREEMENT IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN ALL ACTIVITY OR USE OF THE FACILITIES IN CONNECTION WITH THIS ACTIVITY, THE UNDERSIGNED AGREES TO THE FOLLOWING: THE UNDERSIGNED HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE THE SCV SENIOR CENTER, ITS EMPLOYEES, OFFICERS AND AGENTS (hereinafter referred to as “Releasees”) from all liability to the undersigned, his or her personal representatives, assigns, heirs, and next of kin for any loss, damage, or claim therefore on account of injury to the person or property of the undersigned, whether caused by any negligent act or omission, including gross negligence and/or willful disregard, of the Releasees or otherwise while the undersigned is participating in the any activity or using any of the facility in connection with such activity. ✱ Enter Your Initials* THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND HOLD HARMLESS the Releasees from all liability, claims, demands, causes of action, charges, expenses, and attorney fees (including attorney fees to establish the Releasees’ right to indemnify or incurred on appeal) resulting from involvement in this activity whether caused by any negligent act or omission of the release or otherwise. ✱ Enter Your Initials* THE UNDERSIGNED HEREBY ASSUMES AND ACCEPTS FULL RESPONSIBILITY FOR ANY AND ALL LOSS, BODILY INJURY, DEATH OR PROPERTY DAMAGE while upon the property or participating in the activity or using any of the facility and equipment whether caused by any negligent act or omission of Releasees or otherwise. The undersigned expressly agrees that the foregoing release and waiver, indemnify agreement and assumption of risk are intended to be as broad and inclusive as permitted by California law and that if any portion thereof be held invalid, notwithstanding, the balance shall continue in full legal force and effect. ✱ Enter Your Initials* I hereby acknowledge that I have read the foregoing and that I am aware of the legal consequences of this agreement, including that it prevents me from suing the City or its employees, agents, or officers if I am injured or damaged for any reason because of participation in this activity. I further acknowledge that no oral representations, statements or inducements have been made to me.By my signature below, I signify that I have read, understand, and voluntarily agree to be bound by each of the terms stated above.✱ Signature:* ✱ Date:*
Class Registration Form