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2016-2017 Transportation Services - Registration & Release Form

  1. 2016-2017 Transportation Services - Registration & Release Form

    All resident and non-resident members must have a completed Registration and Emergency Contact Form on file. This confidential, mandatory form is required annually to start, or continue to participate, in all Senior Center programs. Refer to our newsletter “The Maple Street Monthly” for information on additional forms that may be required for program participation. Submit all forms and payment, if applicable, to the receptionist prior to activities. Thank you, Erin R. Graziani, Senior Center Director Revised, 11/01/2016

  2. Do you have any allergies?*

  3. Specify SPECIAL ASSISTANCE you need for transportation services:*

  4. The following information is required if you have a caregiver:

    Note: Caregiver must also complete a Registration & Release Form.

  5. Emergency Contact Person 1

  6. Emergency Contact Person 2

  7. I have received, read and understand the “HANDBOOK & OPERATING PROCEDURES FOR SENIOR CENTER PROGRAMS”. In the event photos are taken I hereby give permission for the Senior Center to use said photos in promotional literature, including brochures, flyers and on the website. To the fullest extent permitted by law, I agree to indemnify and hold harmless the Town of Ellington and its employees from any injuries or damages caused by or resulting from participation in any program offered by the Ellington Senior Center. A photocopy of this waiver form with my signature shall be considered as valid as the original.

  8. Key Tag Needed

  9. Leave This Blank:

  10. This field is not part of the form submission.