Participant Information Form Participant Information Form "*" indicates required fields DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Middle Last Date of Birth*GenderPronouns (optional)Race (Optional) Asian Black Hawaiin / Pacific Islander Native American White Ethnicity (Optional) Hispanic / Latino Non-Hispanic / Non-Latino Home Address* Street Address City State / Province / Region ZIP / Postal Code Is your home address the same as your mailing address? 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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.* I agree I decline 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 WaiverBy typing your name below you are agreeing to Eastern Area Agency on Agings Release Policy. I,* First Last 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. EmailThis field is for validation purposes and should be left unchanged.
