Senior Center Membership Registration Form

Registration Options

Jonesborough City Limits ($20.00)
Washington County Limits ($35.00)
Out of County ($45.00)

Name

Preferred Name

Gender:

Male
Female

Date of Birth

Self-Declared (Initial Age Affidavit below )

Age Affidavit: I declare that I am 60 years of age or older

Phone Number

Yes, it's okay to send me text messages including order confirmations, updates, event reminders, and event information. Message frequency varies. Message and data rates may apply. Reply HELP for help, STOP to cancel. View our terms of service & privacy policy.

Home Address

County:

Complete Mailing or Post Office Box if different than Residential, (If the same please skip)

Mailing Address

County:

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
Unknown

Other:

Does the participant understand English?

Does the participant have a disability that limits activities

Is the income in your household below poverty level?

Name of Emergency Contact:

Relationship

Phone Number for Emergency Contact:

Do you live alone?

Are you a Veteran?

Do you live within the Jonesborough City Limits

Participants Initial (If required by the AAAD)

AUTHORIZATION

Please read and initial each rule below, indicating you understand what’s stated:

I understand that the center/site has a grievance procedure posted that will tell me how to lodge a complaint in the event that I feel I am being discriminated against due to my race, creed, color, sex, age or national origin.

Initial HERE

By signing below I agree that I have read and received a copy of the policy and procedures manual and the information I have provided on this forms is true and correct.

Signature: (type name to indicate you read and understand)

Date:

Liability Waver

I, the undersigned, understand and expressly assume the risk involved in participating in any form of exercise and/or any physical activity or use of exercise equipment at the Jonesborough Area Senior Center, or any other sites utilized by the same agency. I hereby agree to indemnify, save and hold harmless the Jonesborough Area Senior Center, the Town of Jonesborough and/or any agency, individual who volunteers or contracts with the center, to coordinate these activities, for my health, safety, loss of property and injury resulting from my participation in outdoor and/or indoor activities of the Jonesborough Area Center.

To the best of my knowledge, I have no physical restrictions which would prohibit my participating in physical activities. The Jonesborough Area Senior Center, and/or any volunteer representing the senior center have my permission to have emergency medical personnel attend me during my participation of activities at the center, if deemed necessary.

I, the undersigned, grant the Jonesborough Area Senior Center the right to use any still or motion pictures of me during center activities.

Signature: (type name to indicate you read and understand)

Date:

JONESBOROUGH SENIOR CENTER PARKING LOT POLICY

JONESBOROUGH SENIOR CENTER PARKING LOT POLICY

To ensure the safe and efficient movement of vehicles and pedestrians within the Jonesborough Senior Center parking lot, a one-way traffic pattern has been established. This will also help reduce the risk of collisions and congestion.

This policy applies to all employees, members, visitors, contractors, and delivery personnel.

1. All vehicles must travel in the direction indicated by the posted One-Way signs and pavement markings.

A. Entering from Main Street, vehicles must stay to the right (towards the building).

B. Entering from Longview Drive, vehicles must stay straight (area away from the building).

C. Entering from Lincoln Park parking lot, stay to the right (towards the building)

D. If you are parked on the far side of the parking lot and wish to exit to Longview Drive, you still need to observe the one-way traffic pattern and drive around.

E. If you are parked on the near side of the parking lot and wish to exit to Main Street, you still need to observe the one-way traffic pattern and drive around.

2. The portico area is for drop-off and pick-up only.

3. Pedestrian crossings must be respected, and drivers must yield to pedestrians at all marked crosswalks.

4. In the event of an accident due to wrong way driving, the driver of the wrong way vehicle will be held liable.

I, the undersigned, agree to the terms above.

Running Total

$0.00

Coupon Code

Convenience Fee 3% +

$1.00

Total

$1.00

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address

This page is secured with 256 bit encryption