MSC Participant Registration & Waiver

Moveable Senior Center Program

Registration and Waiver
Which events will you attend? (You can choose more than one.)

Oct. 28th - Discussion inspired by Coming Out DayNov. 18th - Thanksgiving EditionDec. 16th - Holiday EditionJan. 27th, 2022 - Rainbow Lunch Hour - Have you read any good books lately?Feb. 28th, 2022 - A New You in 2022Feb. 24th, 2022 - Rainbow Happy Hour - Intergenerational DiscussionMarch 24th, 2022 - Rainbow Lunch Hour - Making Connections.April 28th, 2022 - Rainbow Lunch Hour - Tell A Story
Name*

First NameLast Name
Email*
example@example.com
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Birth Date

MonthDayYear
Best Contact Phone Number
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Emergency Contact Name

First NameLast Name
Phone number for Emergency Contact
Please enter a valid phone number.
Date

MonthDayYear
By typing your name below, you take full responsibility for your voluntary participation in the Moveable Senior Center. You release the sites, instructors, facilitators, presenters, CT Community Care, The CT Healthy Living Collective, their employees, agents or representatives from liability resulting from any injury or discomfort from your attendance and participation.

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 or type your name here to agree to the above:*
Please tell us how you found out about these events.
Senior center, website, social media? Please be specific.
I will be attending the June 24th event:

In person at the Newington Senior & Disabled Centervia ZoomNot sure yet
Should be Empty:

Moveable Senior Center Program