mgcaa  Senior Center Membership Application  Name: Address: Home Phone:  Date of Birth: City: Cell Phone: Email Address: Do' You Drive?  Zip:  Check One: Male Female Doy you live alone? Yes No Areyou a veteran? Yes No Hobbies/nterests:  Yes  No  Emergency Contact Information: (Please List2)  Emergency Contact Name: Phone Number: Emergency Contact Name: Phone Number: Hearing Aid? Yes No Dentures? Primary Doctor: Address: 1.) 5.) 1.) 5.) 1.) 5.)  Relationship: Alternate Phone: Relationship: Alternate Phone:  Medical Information: (Please check all that apply)  Glasses? Walker/ Cane? Yes No  Yes No  Cataracts? Yes No Wheelchair? Yes No  Yes No  Phone:  Medical Conditions  2.) 6.) 2.) 6.) 2.) 6.)  3.) 7.) 3.) 7.) Allergies 3.) 7.)  4.) 8.) 4.) 8.) 4.) 8.)  List all medications    Participant Liability' Waiver and Hold Harmless Agreement: Middle Georgia Community Action Agency, Inc. andt the  mgcaa  Please read this form carefully and! be aware that by registering for and/or participating in programs sponsored by Senior Center, you willl be waiving your rights to all claims fori injuries you might sustain arising out of participation, and you will be required to indemnify, hold harmless and defend Middle Georgia Community Action Agency, Inc. for Risk of Injury: As a participant in Senior Center activities, I recognize and acknowledge that there are certain risks of physical injury, including but not limited to death, and lagree to assume thet full risk ofi injuries, including death, damages, or loss whichlmay sustain as a result of participating in any and all activities associated with Waiver of Injury Claims: agree to waive and relinquish any and all claims I may have arising out of, connected Release from Liability: Idol hereby fully release and discharge Middle Georgia Community Action Agency, Inc. and its officers, agents, and employees from any and all claims from injuries, including death, damage, or loss whichlmay! have or which may occur on account ofp participation in Senior Center activities. Indemnity and Defense: further agree toi indemnify, hold harmless and defend Middle Georgia Community Action Agency, Inc. andi its officers, agents, ande employees from any and all claims from injuries, including death, damages, and losses sustained by me and arising out of, connected with, ori in any way associated with the  any claims arising out of participation in Senior Center activities.  participation.  with, ori in any way associated with the activities of the Senior Center.  activities oft the Senior Center. Senior Center membership.  Ihave read fully and understand and agree to the above-stated conditions of  Ini the event of any emergency, lauthorize Middle Georgia Community Action Agency, Inc. to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed reasonable and necessary for my immediate care and agree that lwill be responsible for payment of any and all medical services rendered to me. Ihave read and fully understand and agree to the above-stated conditions of membership to the  Senior Center.  Client Signature:  Date:  FOR OFFICE USE ONLY: Date Joined: Amount Paid: Payment Processed by: Staff Signature:  Date: