AMP® Participant Waiver & Registration

Aging Mastery Program® Waiver

Participant Waiver and Emergency Card
Name*

First NameLast Name
Your Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Contact Name*

First NameLast Name
Daytime phone number for Emergency Contact *
Please enter a valid phone number.
Do you have any physical limitations that we should be aware of? If yes, please explain. *
Date*

MonthDayYear
By typing your name below, you take full responsibility for your voluntary participation in the Aging Mastery Program being offered at the site listed below. You release the site, the instructors and facilitators, CT Community Care, The CT Healthy Living Collective, and the National Council on Aging, their employees, agents or representatives from liability resulting from any injury or discomfort from your attendance and participation.

You also agree that CT Community Care, Inc., CT Healthy Living Collective and the program location indicated below, their employees, agents or representatives, may photograph you with television, video , movie or still camera. The pictures and any statements or voice recordings made at the time of photography or in connection iwth the photography may be processed in any manner and by whatever method or combination of methods elected. Furthermore, you agree to waive any right or claim you might have to compensation, fees or other benefits by use or reuse of the video/photograph and the undersigned hereby releases the organizers from any claim or demands for compensation or liability arising from said use of or publication of said pictures anywhere in perpetuity. By providing your contact information, you consent to receiving correspondence via mail or email from the CT Healthy Living Collective (CHLC) regarding future CHLC programs.
Sign your name here to agree to the above:*
Please select the Senior Center or other organization which is hosting the Aging Mastery program you will be attending:*

Avon Senior CenterBethel Senior CenterBerlin Senior CenterBloomfield Senior CenterBrookfield Senior CenterCanoe Brook Senior CenterColchester Senior CenterCheshire Senior CenterCreamery Brook Senior CenterEast Hartford Senior CenterGlastonbury Senior CenterGranby Senior CenterGreenwich Senior CenterGroton Senior CenterJCC of Greater New HavenJFS OnlineJFSGNH OnlineChabad of the ShorelineLitchfield Senior CenterLymes Senior CenterMadison Senior CenterManchester Senior CenterMansfield Senior CenterNew Milford Senior CenterNewington Senior & Disabled CenterPomperaug District Dept of HealthRussell Mercier Senior Center, HebronSouth Windsor Senior CenterSouthbury Senior CenterSuffield Senior CenterThe TowersWaterbury Senior CenterWindsor Senior CenterWinsted Senior CenterWoodbridge Senior CenterWestern CT Area Agency on AgingWestern Regional YMCAWinsted Senior CenterWoodbury Senior CenterI am not sure or it's not listed
Should be Empty:

Aging Mastery Program® Waiver