Waiver Form

1 1 9 W . Court St. Ithaca, NY 1 4 8 5 0
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online: tclifelong.org
Waiver Form
Please Print
Personal Information
Name: __________________________________________ Date: ____/____/____
Address: ______________________
City:_______________ State: _______ Zip-Code: ______
Email:_________________________________________________________________________
Municipal Residence: Caroline
Danby
of Ithaca
Town of Ithaca
Dryden
Newfield
Enfield
Ulysses
Groton
Lansing
City
Other:________________
Home #: _______________ Work #: ________________ Cell: #_______________
Gender: ________________ Age: ______ Date of Birth: ______/______/______
Health Information
Please provide any information you believe would be helpful to know if an emergency were to
occur and you were unable to speak for yourself.
List any health conditions you have: _________________________________________________
Do you have any allergies? (e.g. foods or medications)
Yes
No
If yes, please list: _____________________________________________________________
If you have a Primary Care Physician, please list his/her contact information:
Name: _________________________________ Telephone: ______________________________
Emer gency Contacts
Name: ___________________________________ Relationship: __________________________
Address: _______________________________________________________________________
Home #: __________________ Work #: ___________________ Cell: #_____________________
Check here if the person listed above is your Health Care Proxy.
Name: ___________________________________ Relationship: __________________________
Address: _______________________________________________________________________
Home #: __________________ Work #: ___________________ Cell: #_____________________
I don’t have a Health Care Proxy, but I would like to learn more.
Demographic Information (Optional)
White or Caucasian (not of Hispanic origin)
Asian or Pacific Islander
Black or African American
American Indian or Alaska Native
Other: __________________Do you identify as any of the following?
Person with a Disability
Disabled Veteran
Continues on back
Veteran
Hispanic
Multi-Ethnic
Yes
No
Vietnam Era Veteran
Acknowledgment of Risk & Release of Liability
I, the undersigned, hereby apply to participate in activities (classes, programs, events, and trips)
to be conducted by LIFELONG and acknowledge the following: I fully understand and
acknowledge that there are inherent risks and dangers in my participation in the activities and
my participation in said activities and use of any equipment or materials related to such
activities may result in my injury, illness or death and damage to or loss of my personal
property. I understand other participations, accidents, forces of nature or other causes may
cause these risks and dangers and I hereby fully acknowledge and accept these risks and
dangers. I am in good health and I am able to participate in any strenuous physical activity
associated therewith. I understand and agree it is my responsibility to get any medical
clearance or approval from my medical health professional to participate.
I herewith release, forever discharge and waive any right of recovery or subrogation against
LIFELONG, its officers, directors, employees and volunteers from any and all liability
whatsoever for any illness or injury, including death or damage to or loss of my personal
property that I may sustain while I am participating in this program. This shall be binding on my
heirs, successors, assigns, administrators and executors. Any claims or disputes arising out of
my participation in the activity shall first be submitted to arbitration and/or be venued in the
Supreme Court of the State of New York of Tompkins County. I HAVE READ THE ABOVE
OR I ACKNOWLEDGE, THAT I HAVE HAD THIS DOCUMENT READ TO ME AT MY
REQUEST AND BY SIGNING IT I AGREE IT IS MY INTENTION TO PARTICIPATE IN
ACTIVITIES AND I UNDERSTAND AND ACCEPT ALL RISKS INVOLVED.
NAME (PRINT): ______________________________________________________________
SIGNATURE: _________________________________________ DATE: _____/_____/_____
LEGAL GUARDIAN SIGNATURE: _______________________ DATE: _____/_____/_____
IF PARTICIPANT IS UNDER THE AGE OF 18 YEARS OLD
Photo Release: For good and valuable consideration herein acknowledged as received, I hereby grant
Tompkins County Senior Citizens Council, Inc. (dba Lifelong), its legal representatives and assigns,
those for whom said corporation is acting, and those acting with its authority and permission, the
absolute right to copyright and use, reuse, publish and republish any or all video/audio tapes,
photographs, negatives, or prints taken of me by representatives of said corporation, without restriction
as to changes or alterations from time to time, in conjunction with my name or a fictitious name in any
medium for art, advertising, trade, or any other purpose whatsoever. I hereby waive any right that I
may have to inspect or approve the finished product or products or advertising copy or printed or
electronic matter that may be used in connection therewith or the use to which it may be applied. I
hereby release, discharge and agree to save harmless Tompkins County Senior Citizens Council, Inc., its
legal representatives or assigns, and all persons acting under its permission or authority or those for
whom it is acting, from any liability by virtue of any blurring, distortion, alteration, optical/audio
illusion, or use in composite form that may occur or be produced in the creation and production of any
of these materials. I hereby warrant I am of full age and have every right to contract in the above regard.
I state further that I have read the above authorization, release and agreement, prior to its execution, and
I am fully familiar with the contents thereof.
Name:___________________________________Signature: _________________________________