Connecting Generations, Strengthening Communities
Senior Program Application
Senior Name
Date of Birth
Address
Home Tele #
Cell #
The fee to join our Elderly Program is $20.00 a month. Fundraising or payment plan will be necessary to defray cost of special events.
Amenities:
Open Monday through Fridays from 9:00 A.M. to 2:00 P.M.
MEDICAL INFORMATION
Special Needs and Accommodations
Known Allergies Natural/Food
Nutrition Concerns
Other Concerns
Insurance Carrier
Insurance ID
Senior's Physician
Phone #
Address
EMERGENCY AUTHORIZATION
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I give my consent for the First Aid and CPR certified staff of program Monica Clark to administer first aid and CPR to my child and to contact the above named physician if my child has a medical emergency. I also give my consent for my child to be transported to the nearest hospital in the event of a medical emergency. I will be responsible for all medical fees.
Preferred Medical Facility
BEHAVIOR MANAGEMENT and PARENT HANDBOOK
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I acknowledge that I have read the parent handbook and agree to abide by the policies contained in it and that the techniques used to manage child behaviors in the facility have been discussed with me prior to enrollment.
WAIVER of LIABILITY
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In consideration of being permitted to participate in 333 Valley Street An Inter-generational Organization, Inc. programs, activities and use of facilities and equipment, I accept all risk to and my family for injuries that may occur. I hereby release 333 Valley Street An Intergenerational Organization, Inc, its Board of Directors, officers, employees, volunteers and representatives from any and all liability for any and all claims and causes for action from loss or damages to me and/or any family injuries or property.
Read terms and conditions below.
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333 Valley Street An Intergenerational Organization, Inc. (Shack) is not responsible for the loss or damage of valuables/property of members/guest. I agree to abide by policies, rules and regulations of the Shack which may be amended from time to time and to behave with appropriate conduct which would include damage, or destruction of property, theft, to follow proper safety precautions and practices, to display appropriate behavior, no fighting, harassment including physical and verbal abuse of other participants and staff. Photo/Video Authorization: I hereby authorize release of my child’s name and photograph for possible news release concerning 333 Valley Street An Intergenerational Organization, Inc. I understand that my child may take photographs or videos of the programs or activities in which they are participating. I give permission for to the Shack to use photographs or videos for the purpose of promoting the organization and its programs. I give permission with the understanding no compensation of any kind will be paid to me or my family at this time or the future.
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