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Application 2010

Application 2010

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Published by Angie Wennerlind

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Published by: Angie Wennerlind on Dec 28, 2011
Copyright:Attribution Non-commercial

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01/06/2012

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High Point Village Enrichment Center Registration Form
TODAY’S DATE ____________LAST NAME _________________________ FIRST____________________MI________SEX _____RACE ___________________ DATE OF BIRTH _______/________/________AGE ____ PHONE (____) ____________EMAIL_________________________________ADDRESS__________________________________________________________________CITY ________________________ STATE _________ ZIP _______________________NUMBER OF PERSONS IN HOUSEHOLD_____________________________________EMERGENCY CONTACT DATA:
 Name Relationship AddressWork Phone
___________________
 Home Phone Cell Phone
OVERALL FUNCTIONAL AND MEDICAL STATUS
DISABILITY:________________________________________________________________________MEDICATIONS:________________________________________________________________________MEDICAL CONDITIONS:___________________________________________________________ ______PHYSICAL CONDITIONS:________ _______________________ __________ALLERGIES:________________________________________________________________________
 
 
 
Primary Physician:Physician Phone Number:Pharmacy:
INFORMATION RELEASE
I certify that the above information is correct. I hereby grant permission to High PointVillageand volunteers working under the direction of High Point Villageto use thisinformation for the following purposes ONLY: (1) to include myinformationfor grant(funding) purposes (2) to give to emergency response agencies for assistance withevacuation or aid in the event of a disaster or emergency. This information isconfidential.
SIGNATURE: DATE:
RELEASE OF LIABILITY WAIVER
I, ___________________________________________for myself, representatives, or minors,hereby release, waive, and covenant not to sue High Point Village, its employees, andvolunteers, from any and all claims of negligence of High Point Village, its employeesand volunteers, resulting in personal injury, illness, and death arising from but not limited to participation in High Point Village activities.Participation in activities in High Point Village Enrichment Center activities carrieswith it certain risks that cannot be eliminated regardless of the care taken to avoidinjuries. The specific risks vary from one activity to the next and can range from1)Minor bruises, scratches, and sprains 2) major injuries such as eye damage, joint or back injuries, and concussions 3) catastrophic injuries including paralysis anddeath.I have read the following paragraphs and know and appreciate these and other risksare involved in High Point Village programs. I hereby assert that my participation isvoluntary and that I knowingly assume all risks.I also agree to indemnify and hold harmless High Point Village from any actions,claims, suits, procedures, costs, expense, liabilities, including attorney’s fees brought 
 
 as a result of my participation in these activities and to reimburse them from anyexpense incurred.I have read this waiver of liability, assumption of risk, and indemnity agreement,fully understand its terms, and understand that I am giving up substantial rights,including my right to sue. I acknowledge that I am signing this agreement freely andvoluntarily and intend by my signature to be a complete and unconditional releaseof all liability to the greatest extent allowed by law.
DATE______________________ SIGNATURE____________________________________________________
PHOTO RELEASE
I hereby authorize High Point Village to publish the photographs taken of the me and/orthe undersigned minor children, and our names, for use in the High Point Village’sprinted publications and website.I release High Point Village from any expectation of confidentiality for the undersignedminor children and myself and attest that I am the parent or legal guardian of the childrenlisted below and that I have the authority to authorize High Point Village to use theirphotographs and names. I acknowledge that since participation in publications andwebsites produced by High Point Village is voluntary, neither the minor children nor Iwill receive financial compensation.I further agree that participation in any publication and website produced by High PointVillage confers no rights of ownership whatsoever. I release High Point Village, itscontractors and its employees from liability for any claims by me or any third party inconnection with my participation or the participation of the undersigned minor children.Signature: ________________________________ Date: ______________________Street Address: ________________________________________________________City, State, Zip: _______________________________________________________Names and Ages Children: Name:Name:______________________________________ Age: _____Name:______________________________________ Age: _____
 

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