Senior Program Activity Waiver Form
Please complete this waiver form to participate in the selected senior program activity.
Participant Full Name
*
First Name
Last Name
Participant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Activity or Program Joining
*
Relevant Safety or Medical Notes (only as needed for participation)
Participant Signature
*
Date of Agreement
*
-
Month
-
Day
Year
Date
Submit Waiver
Submit Waiver
Should be Empty: