Form Center

1. Membership Information This section is complete This section is incomplete
2. Emergency Contact This section is complete This section is incomplete
3. Program Participation Release This section is complete This section is incomplete
4. Policy Agreement This section is complete This section is incomplete
5. Optional Information This section is complete This section is incomplete

Membership Information

Date
Date
Are you a U.S. veteran?
1. Yes
2. No
If so, what branch?
Name
Date of Birth
Date of Birth
Address
City
State
Zip Code
Home Phone
Cell Phone
Are you able to receive text messages for class alerts and closings?
1. Yes
2. No
Email
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I, request that I be allowed to participate in the program / activity at the Woodie Fite Senior Center.
To my knowledge I do not have any medical or other condition which would prevent me from participating in the program / activity. I also acknowledge that if I have any reservations or concerns about my medical condition, it is my responsibility to consult with the appropriate medical personnel prior to participating in the program / activity.
I understand that my participation is strictly voluntary. In addition, on behalf of myself, my heirs and next of kin, I release Douglas County, it’s officials, employees, volunteers and agents and the Woodie Fite Senior Center from any and all liability or responsibility for any and all injuries and/or illnesses resulting from my attendance at or participation in any program or activities related to the Woodie Fite Senior Center.
I understand and agree that any photos or video of myself may be used on social media or in publications for the Woodie Fite Senior Center.
I am satisfied that I understand the potential risks of this program/activity. I do hereby plan to participate in the programs and/or activities provided at the Woodie Fite Senior Center.
Electronic Signature
Date
Date
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I have received the New Member Information Pamphlet and I agree to adhere to the Woodie Fite Senior Center policies for the privilege of membership at the Woodie Fite Senior Center.
Electronic Signature
Date
Date
When a member is unable to operate independently, a caregiver/support attendant, designated by the member, may attend activities sponsored by the center in order to assist the member in need. A caregiver/support attendant attending with a member will not be required to pay tuition for the class, however should the caregiver/support attendant choose to participate in the class, they must pay the activity fee, supply fee or other miscellaneous fees. The caregiver/support attendant does not need to meet the age requirement for membership, to attend with the member in need of their assistance. The caregiver/support attendant will be required to meet the age requirement should they choose to participate in any activity. The caregiver/support attendant will be required to remain with the member during the class or activity.
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