enrollment form

I, the undersigned, being aware of my own health and physical condition am voluntarily participation in activities which may include activities such as exercise programs and therefore have knowledge that my participation in any activities and exercise programs may be injurious to my health. Having such knowledge, I hereby acknowledge this release, and hold harmless any representatives, agents, and successors or Senior Action from liability for accidental injury or illness which I may incur as a result of participating in the said activities. I hereby assume all risks associated therewith and consent to participate in said program(s). I agree to disclose any physical limitation, disabilities, ailments or impairments which may affect my ability to participate in said programs, including exercise and fitness activities. Ii also acknowledge that I have received and read; understand and will abide by Senior Action’s Participation Expectations. Senior Action like to include photographs of our members enjoying life in various publications. Please let us know if you DO NOT want Senior Action to use your picture in publications and promotional pieces. Additionally, Senior Action will email information about programs and services to the email listed on this form.