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Here below you will read the registration form/waiver.
Please, you should copy it, print it, fill it, and sign it.
Then you have to email it back to us at info@caregivercare.org
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REGISTRATION FORM
First name _______________________________
Last Name ___________________________________
Street Address____________________________________________________________
Age ____________ Telephone number ________________________________________
Email Address ______________________________________________________
Do you belong to the Our Lady of Good Counsel and St. Thomas More Parish? Yes / No
If not, how did you learn about these programs? ___________________________________________
WAIVER AND LIABILITY AGREEMENT
BY ATTENDING THE FREE OF CHARGE LIVE ONLINE CAREGIVERCARE CLASSES, PROVIDED BY “GP DEMENTIA SERVICES NEW YORK” YOU HEREBY AGREE TO THE FOLLOWING:
- I AM PARTICIPATING IN THESE INSTRUCTIONS OFFERED BY “GP DEMENTIA SERVICES NEW YORK”, THROUGH THE APPLICATION “ZOOM,” OF THE LIVE STREAMING OF CAREGIVERCARE CLASSES THAT INCLUDES CHAIR YOGA, STRESS MANAGEMENT, DANCE THERAPY, ITALIAN CLASS, AND ITALIAN MOVIE FOLLOWED BY DISCUSSIONS AND INSIGHTS ABOUT THE MOVIE.
- I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO ENSURE MY INTERNET CONNECTION IS WORKING BEFORE, DURING, AND AFTER THE LIVE ONLINE CLASS PROVIDED BY “GP DEMENTIA SERVICES NEW YORK”
- I I UNDERSTAND THAT IT IS MY RESPONSIBILITY PRIOR TO ANY ONLINE CLASSES TO CONSULT WITH MY DOCTOR ABOUT ANY EXISTING OR PRE- EXISTING HEALTH CONDITIONS/INJURIES I MAY HAVE. I REPRESENT AND WARRANT THAT I AM PHYSICALLY FIT AND I HAVE NO MEDICAL CONDITION THAT WOULD PREVENT MY FULL INVOLVEMENT IN THE LIVE ONLINE CLASSES.
- IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN THE CLASSES OFFERED BY “GP DEMENTIA SERVICES NEW YORK”, I AGREE TO TAKE FULL RESPONSIBILITY FOR ANY RISKS, INJURIES, DAMAGES, KNOWN OR UNKNOWN, THAT I MIGHT INCUR AS A RESULT OF MY ATTENDANCE.
I, KNOWINGLY, VOLUNTARILY AND EXPRESSLY WAIVE ANY CLAIM I MAY SUSTAIN AS A RESULT OF MY ACTIVE PARTICIPATON IN THE LIVE ONLINE CAREGIVERCARE CLASSES.
I HAVE READ THE ABOVE RELEASE AND WAIVER OF LIABILITY AND FULLY UNDERSTAND ITS CONTENTS. I VOLUNTARILY AGREE TO THE TERMS AND CONDITIONS STATED ABOVE.
Date ________________ Signature________________________________________________________
