Adult Day Programs Rochester ESLC

Membership Form

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

Email:

Date of Birth

Check One:
 Male Female

Select which Program you are registering for:
 East Avenue Gates Henrietta Honeoye Falls Northeast Greece South Wedge Westside

Emergency Contact Information

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

Medical Information

*As with any exercise program, we recommend consulting with your physician prior to participating.

Primary Care Physician:

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Preferred Phone:

Alternate Phone:

In the event of an emergency, where would you prefer to be taken?
 Highland Unity Strong Rochester General Thompson

Neighborhood Program Liability Waiver

agrees in exchange for my participation in any Neighborhood Outreach Programs organized by Episcopal SeniorLife Communities (“ESLC”) to
adhere to the following:

I will agree to obey and observe any and all posted warnings and rules, and agree to follow any directions or oral instructions given by ESLC, or the employees, representatives, affiliates, or agents of ESLC.

I understand that my time spent at ESLC and any of its affiliated sites may include various activities that may be hazardous to my health. I hereby expressly and specifically assume the risk of injury or harm in these activities and release ESLC, its partners, affiliates, employees, representatives, and agents from any and all liability for injury, illness, loss, death, or property resulting from my activities of my use and presence upon the facilities whether cause by fault of myself, ESLC and its affiliates, or a third party. I understand that I am participating in these activities at my own risk.

I agree to indemnify and hold harmless ESLC, its affiliates, and its representative officers, employees, agents, and directors from any and all claims, demands, losses, causes of action, lawsuits, damage, judgments, including attorneys’ fees and costs, arising out of my presence at ESLC and any of its affiliated sites and partner sites.

In the event of damages, I agree to pay for any and all damages caused by my presence at ESLC, or at an affiliated site.

Any equitable or legal claim or claims that may arise from my participation in the above activity shall be resolved under the laws of New York State.

I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE I AM VOLUNTARILY SURRENDERING CERTAIN LEGAL RIGHTS.

Participant's Signature:

Date: