Annual Registration Form

First Namerequired

Last Namerequired

Date of Birthrequired (mm/dd/yyyy)

Home Phone Numberrequired

Cell Phone Number

Address 1required

Address 2

Cityrequired

Staterequired

Ziprequired (ex. 06108 or 06108-0809)

Email Address

Emergency Contact Namerequired

Emergency Contact Phone Numberrequired

Do You Have Allergies?

Medications Food Environmental Other

Other Allergies?

Are you interested in our Transportation services?

Yes No

In the event photos are taken at a Senior Center function, do you give us permission to use said photos in promotional literature, brochures, flyers, on social media and the Senior Center website?

Yes No

Hold Harmless Agreement

To the fullest extent permitted by law, the undersigned participant, for themselves, their heirs, successors, executors, administrators and assigns, hereby agrees to RELEASE, INDEMNIFY AND HOLD HARMLESS the Town of Ellington, its officers, employees, agents and volunteers, from and against any and all losses, actions, causes of actions, suits, controversies, damages, judgments, executions, claims and demands whatsoever in law or in equity, including reasonable attorneys fees, that may arise out of the undersigned’s participation in any activity or program offered by the Town of Ellington or the Senior Center, including but not limited to those arising from loss of life, personal injury and/or property damage.

Signaturerequired

Date required (mm/dd/yyyy)

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.

Signaturerequired

Date required (mm/dd/yyyy)