Senior Center Participant Registration Form

Registration Options

Jonesborough City Limits ($15.00)
Washington County Limits ($25.00)
Out of County ($35.00)

Name

Maiden Name

"Also Known As":

Phone Number

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Cell Phone Number

Residential Address

County:

Is your Mailing Address different than Residential Address

Mailing Address

County:

Gender:

Male
Female

Date of Birth

Staff who saw documentation. (This may be filled out at Senior Center)

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?

Do you live within the Jonesborough City Limits

Name of Emergency Contact (other than spouse):

Phone Number for Emergency Contact:

Phone Number for Primary Physician:

Name of Primary Physician:

NUTRITION SITE ONLY

What reason is the participant eligible for congregate meals?

Age 60 +
Non-elderly disabled individual residing with eligible person or living on site.
Spouse of 60+ participant

If none of the above, is the participant a site volunteer/worker

Is the participant at a high nutritional risk

AUTHORIZATION

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

I understand that I have to be 60 years of age or older to participate in the meal program and that the date of birth entered above is correct to the best of my knowledge.

Initial HERE

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:

Other Interest:

We appreciate the contribution of our Volunteers!! Our senior community benefits greatly when you share your gifts and talents. We will follow up with you or feel free to contact our Volunteer Coordination at 423.753.4852 for more information.

Monthly Newsletter and Updates by email:

Email address:

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

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