Membership Form

The health & safety of our members is a top priority. Seniors In Action adheres to the safety & risk prevention measures for all our programs & services. The following data is for the purpose of ensuring your safety during the program(s)

First Name

Last Name

Date of birth

Phone

Email

Address

Street Address

City

State

Country

Postal Code

Gender

Male

Female

Rather not say

Language

I understand that participation in Seniors In Action activities may involve health or injury risks and confirm I have medical clearance. I accept full responsibility for myself (or the person in my care) and release Seniors In Action, its staff, and affiliates from any claims, damages, or liabilities arising from participation. I also agree to indemnify and defend them against any related claims or costs.

By affixing your signature below, you acknowledge your membership and responsibility in SIA. Members are able to participate in SIA programs upon proof of paid membership prior to enrollment. Annual fees and other related payments are to be used towards general project costs.

Your Signature

Clear

Date Signed

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