* Required

2021-2022 Registration & Release Form

Participants are required to have ALL of the forms below signed and on-file annually, either to start, or continue to participate, in all Senior Center programs and services:

Annual Registration & Release Form (including COVID Participant Registration Waiver)

All forms can be found online at http://seniorcenter.ellington-ct.gov.  If you cannot obtain the forms online, please call 860-870-3133 for a copy to be mailed to you. Revised, 3/23/2021

PARTICIPANT REGISTRATION INFORMATION
EMERGENCY CONTACT #1

EMERGENCY CONTACT #2

SENIOR CENTER ALERTS AND MESSAGES

If you would like alerts and messages such as cancellations, weather closings, emergency notifications, special programs, newsletter, etc. please provide the following information:
(Ellington Senior Center is not responsible for any charges you may receive from your provider due to receiving text alerts or messages on your cell phone).

USE OF YOUR PICTURE/PHOTOS TAKEN

In the event photos are taken at a Senior Center function, I hereby give permission for the Senior Center to use said photos in promotional literature, brochures, flyers, on social media and the Senior Center website.  

TRANSPORTATION NEEDS

Transportation is available to Ellington residents only. 

Drivers are unable to assist you with climbing stairs, carrying bags, etc.  If you are unable to utilize transportation services independently, you can have a companion accompany you.  The Senior Center does not provide companions and suggests speaking with your doctor’s office for a recommendation if you are in need.

If you already have a companion who will be accompanying you, please provide their name and contact information.

HOLD HARMLESS AGREEMENT

To the fullest extent permitted by law, while participating in programs offered by the Town of Ellington, Senior Center or any activity held at another location, I, for myself, my heirs, successors, executors, administrators and assigns, knowingly and voluntarily do hereby RELEASE, INDEMNIFY and HOLD HARMLESS the Town of Ellington, its officers, employees and agents from and against any and all losses, claims, costs, damages, judgments, suits and expenses, including reasonable attorney’s fees arising from, alleged to arise from, or resulting in personal injury to me, any third party, or my property and from and against any claims of injuries or damages that I may cause to any person or property. I do understand that if I am injured while participating in programs, I will report it immediately, but as I am not an employee of the Town of Ellington I have no right to claim a worker’s compensation injury. Further, that I will be responsible for any medical bills should I become injured. I also know that I am not authorized to use power tools. The use of media equipment for programs is permissible.

Agreement of Participant:

Ellington Senior Center Participant Registration Waiver

NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Please read this document in its entirety.
 

The novel coronavirus, COVID-19, is considered a global pandemic and is scientifically proven to be highly contagious.  Federal and state entities, as well as the Town of Ellington, recommend social distancing and heightened sanitation practices as a means of mitigating the spread of COVID-19. 

The health and safety of all Town of Ellington Senior Center participants and staff remains the Town of Ellington’s top priority.  The Town of Ellington will adhere to all executive orders and health mandates issued by the State of Connecticut and state and federal agencies regarding the COVID-19 pandemic.  Additionally, the Town of Ellington will provide all required COVID-19 testing, adhere to enhanced health procedure requirements as provided by the State of Connecticut, and may conduct random testing.  The Town of Ellington cannot guarantee that all environments are insulated from COVID-19, and cannot guarantee that participants, staff and volunteers will not be infected with COVID-19.

By signing this Waiver, I certify that I have received notice that (1) people who are 65 years and older, and people of any age with serious underlying medical conditions or who are at higher risk for severe illness from COVID-19, are recommended to stay at home; and (2) those living in households with individuals who are 65 years and older, or have higher risk for severe illness from COVID-19, are recommended to stay home. 

By signing this Waiver, I certify that I am presently in good health and have no impairments or conditions which would restrict participation in a Town of Ellington Senior Center program.  I further certify that I will provide prompt notice to the Senior Center Director if symptoms manifest and will immediately remove myself from the Town of Ellington Senior Center program until receiving written medical clearance to return. I further certify that I am aware of the State of Connecticut’s travel advisory issued pursuant to Executive Order No. 7III and I will refrain from attending and/or participating in any Senior Center program if doing so will result in a violation of that Order.  I further certify that, pursuant to Executive Order No. 7NNN, I will wear a mask or suitable facial covering that covers my nose and mouth when participating in any Senior Center program or activity and a six-foot distance between others is unavoidable, whether indoors or outdoors. 

By signing this Waiver, I acknowledge the highly contagious nature of COVID-19 and voluntarily agree to the participation terms set forth above.  I further agree to assume the risk that participants and family members may be exposed to, or infected by, COVID-19 by attending activities and that such exposure or infection may result in personal injury, illness, temporary or permanent disability, or death.  I understand that the risk of being exposed to or infected by COVID-19 at a Town of Ellington Senior Center program may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, volunteers, agents and representatives.  I voluntarily agree to assume all of the foregoing risks, and I accept sole responsibility for any injury, loss, damage, expense, or liability to myself or other family members that may occur now or in the future due to attendance and participation in a Town of Ellington Senior Center program.

I, my heirs, representatives, executors, administrators and assigns, do hereby release, discharge and hold harmless the Town of Ellington and all employees, volunteers, agents and representatives from any claims and any liability related to COVID-19 arising from my own participation in the Town of Ellington Senior Center activities and my presence in the Town of Ellington Senior Center. 

In signing this Waiver, I acknowledge and represent that I have read the foregoing Waiver, I am fully competent to understand and sign this Waiver, and I sign it voluntarily as my own free act and deed.


Please provide an email address where we can send a link to your current form.

Email Address :