Participant Information Form

Participant Information Form

"*" indicates required fields

Date
Name*
Race (Optional)
Ethnicity (Optional)
Home Address*
Is your home address the same as your mailing address?
Mailing Address (If different than Home Address)
If Different than Home phone
My preferred phone number is :
I would like to receive EAAA's Newsletter

Emergency Contact Information

Emergency Contact #1 Name*

Program Information

Public Media Relations Statement (optional)

to release and hold harmless Eastern Area Agency on Aging from any and all liability, claims, demands, costs, and damages of any kind, including personal injury, bodily injury, illness, property damage, loss or death. I understand that by signing this release I assume the risk of injury, harm, damage, and loss associated with the Activities. I also understand that the agency does not assume any responsibility for provision of financial assistance including medical, health or disability insurance in the event of injury, illness, or property damage. I, acknowledge that I have received the Durgin Center Code of Conduct. By accepting the Durgin Center Code of Conduct and acknowledging its receipt, I agree to follow the policies and procedures, and understand that any breach of this agreement may result in my dismissal.*
to release and hold harmless Eastern Area Agency on Aging from any and all liability, claims, demands, costs, and damages of any kind, including personal injury, bodily injury, illness, property damage, loss or death. I understand that by signing this release I assume the risk of injury, harm, damage, and loss associated with the Activities. I also understand that the agency does not assume any responsibility for provision of financial assistance including medical, health or disability insurance in the event of injury, illness, or property damage. I, acknowledge that I have received the Durgin Center Code of Conduct. By accepting the Durgin Center Code of Conduct and acknowledging its receipt, I agree to follow the policies and procedures, and understand that any breach of this agreement may result in my dismissal.

Release and Waiver

By typing your name below you are agreeing to Eastern Area Agency on Agings Release Policy.
I,*
do release and hold harmless Eastern Area Agency on Aging from any and all liability, claims, demands, costs, and damages of any kind, including personal injury, bodily injury, illness, property damage, loss or death. I understand that by signing this release I assume the risk of injury, harm, damage, and loss associated with the Activities. I also understand that the agency does not assume any responsibility for provision of financial assistance including medical, health or disability insurance in the event of injury, illness, or property damage. I, acknowledge that I have received the Durgin Center Code of Conduct. By accepting the Durgin Center Code of Conduct and acknowledging its receipt, I agree to follow the policies and procedures, and understand that any breach of this agreement may result in my dismissal.
This field is for validation purposes and should be left unchanged.