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2. 
4. Name (First, Last, M.I.)*
5. Today's Date*
   Today's Date
6. Birth Date *
8. Address *
10. City*
11. Zip Code*
13. County *
14. State
15. Gender *

    1. M
    2. F
    3. Non-binary
17. Home Phone Number*
18. Cell Phone Number*
19. Email *
21. Emergency Contact Information
23. Name *
24. Relation *
25. Phone Number *
27. How Did You Learn About Our Senior Centers?*
29. Ethnicity (Check all that apply)

    1. Alaska Native/American Indian
    2. Asian
    3. Black/African American
    4. Hispanic/Latino
    5. Native Hawaiian/Pacific Islander
    6. White-Caucasian/Non-Hispanic
30. US Veteran

    1. Yes
    2. No
31. Branch

    1. Air Force
    2. Army
    3. Coast Guard
    4. Marines
    5. Navy

33. If you are interested in volunteering, use this link to find volunteer opportunities: (www.orangecountync.gov/VC55Opportunities).Please ask for an application at the front desk of either the Passmore or Seymour Centers, or email spell@orangecountync.gov

35. Orange County Senior Centers Rules of Personal Conduct for Participants *

    1. I have read and understand the Rules of Personal Conduct. By checking the box and typing my name below, I am electronically signing the Rules of Personal Conduct.

    The Orange County Department on Aging’s Senior Centers are designed to be a safe place for physical and intellectual stimulation and mutual social support for older adults. It is the policy of ALL Orange County SeniorCenters that all participants respect the personal and professional boundaries of one another—this means treating all other participants, volunteers and staff with respect at all times. All participants must comply with staff instructions and facility policies to ensure a safe and welcoming environment for everyone. Please do not make others feel uncomfortable or unsafe by physically touching them without their specific permission to do so – NO TOUCHING OF PRIVATE PERSONAL BODY PARTS IS ALLOWED. If a participant demonstrates disrespectful, inappropriate or hurtful actions, including but not limited to discourteous language toward staff or participants, refusing to follow staff directives, unauthorized use of facilities, inappropriate spoken words, physical gestures, or written communication, unwanted touching or suggestive language and abuse of County property, will be requested by the Department on Aging management to discontinue the objectionable behavior and if necessary to leave the facility. If it is deemed that an action rises to the level of criminality, local law enforcement will be notified and the accused may be temporarily or permanently banned from one or both Orange County Senior Centers.(Approved by the Orange County Advisory Board on Aging on August 12, 2025.)

37. Electronic Signature
38. Date*
    Date
40. Orange County Department on Aging Waiver*

    1. I have read and understand the Orange County Department on Aging Waiver. By checking the box and typing my name below, I am electronically signing the Orange County Department on Aging Waiver.

    In consideration of my participation in the aforementioned Orange County Department on Aging program or activity, I, my heirs, executors, administrators, successors and assigns, hereby release and discharge Orange County, and all of its officers, agents, employees and successors, from any and all claims, actions, causes of action, damages, costs or other liabilities, known or unknown, foreseen or unforeseen, arising from any programs or activities conducted as part of Orange CountyDepartment of Aging Program(s).This release shall be binding on all their heirs, executors, personal representatives, administrators, successors and assigns. It is the intention of the parties that this Release shall be construed as broadly as permitted by applicable law.I consent to transportation by Orange County employees or agents for all program activities, events and travel excursions while acknowledging that neither Orange County employees nor any sponsoring agent provides individual accident or general liability insurance coverage for participants. I understand that I am responsible for my own medical and personal insurance coverage, and I voluntarily accept all inherent risks associated with participation in Orange County travel programs.

42. Electronic Signature*
43. Date*
    Date
45. Wellness Program Waiver

    1. I have read and understand the Wellness Program Waiver. By checking the box and typing my name below, I am electronically signing the Wellness Program Waiver.

    Please Note: This program requires physical activity that may present problems if certain medical conditions currently exist. It is our recommendation that the participants consult their physician if they have any questions or concerns about participation in this program. It is our belief that by taking a few precautions, this will be a safe and fulfilling program for all involved.All Participants involved in Wellness program exercise classes must sign this liability waiver.I, the undersigned participant, hereby agree to hold harmless any persons or organizations involved with Wellness program exercise classes, use of fitness room equipment and outdoor Fitlot facilities, as well as owners, proprietors and employees of all facilities, from any legal action or claims at any time because of my participation in this exercise class or use of exercise equipment and facilities. I have informed the Orange County staff of any physical conditions that may hinder my participation in the program or activity. I am in good enough physical condition to participate safely. I hereby grant permission to any licensed medical facility and/or my physician to provide treatment as deemed necessary for my well-being. I hereby grant the Wellness Program of the Orange County Department on Aging permission to use any photographic likeness taken.

47. Electronic Signature
48. Date*
    Date

50. 
    THANK YOU!

    Passmore Center

    POB 8181 (Mailing Address) 
    103 Meadowlands Dr. (Physical Address) 
    Hillsborough, NC 27278 
    Phone: (919) 245-2015

51. Seymour Center

    2551 Homestead Rd. 
    Chapel Hill, NC 27516 
    Phone: 919-968-2070

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54. Email address

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