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2. 
4. Name (Last, First, MI)
5. Today's Date
7. Address
9. City
10. State
11. Zip Code
13. Phone
14. *Cell Phone
15. Date of Birth
17. *Text Message Option

    *We would like to text message you occasional special event, program cancelation, and closure notices. Carrier rates may apply. To consent, please check YES; to decline, check NO in the "Text Message Consent" field to the right:

18. Text Message Consent

    1. YES, I would like to receive occasional text messages.
    2. NO, I do not want to receive text messages.
20. Email
21. Gender
    -- Select One --MaleFemaleNon-binary
23. Are you a veteran?

    1. Yes
    2. No
24. If so, what branch of the military?

    1. Air Force
    2. Army
    3. Coast Guard

    1. Marines
    2. Navy
26. Optional Ethnicity Information:

    1. Alaska Native/American Indian
    2. Asian
    3. Black/African-American
    4. Hispanci/Latino

    1. Native Hawaiian/Pacific Islander
    2. White-Caucasian/Non-Hispanic
    3. Other
28. Emergency Contact Information:
30. 1) Name
31. Best Contact Number
33. 2) Name
34. Best Contact Number
36. How did you hear about us?

    1. Brochure
    2. E-newsletter
    3. Endless Possibilities Activity Guide

    1. Friend/Family
    2. Internet
    3. Newspaper

    1. Social Media
    2. Other
38. If you selected "Other," please explain.
40. Volunteer: I would like to explore volunteer opportunities?

    1. Yes
    2. No

    If you answered yes, staff from the department's Volunteer Connect 55+ division will contact you.
42. Interests and Skills
44. Which senior center do you think you will attend more often?
    -- Select One --Passmore Center - 103 Meadowlands Dr., Hillsborough, NC 27278Seymour Center - 2551 Homestead Rd., Chapel Hill, NC 27516

    Choosing one center does not exclude you from participating in the other.
48. Orange County Senior Centers Rules of Personal Conduct for Participants
    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 Senior Centers 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. 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 spoken words, physical gestures, unwanted touching, suggestive language and/or written communication to others, they 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 Nov. 6, 2018)
50. DISCLAIMER
    By typing your name below, you are signing "Orange County Senior Centers' Rules of Personal Conduct for Participants" electronically. You agree that you have read and understand the rules of conduct, and that your electronic signature is the legal equivalent of your manual signature on this application. If you prefer not to sign electronically, please leave this form and visit the link at the right for a hardcopy.
51. Alternate Hardcopy
    Senior Center Programs
53. Signature
54. Date/Time
    Date/Time

    Date/Time
58. 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 County Department 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. To the extent allowed by law, I also consent to the transportation of myself by above said employees or agents to and from such programs or activities conducted as part of this Orange County Department on Aging program. I further understand that individual accident and general liability insurance coverage is not provided by Orange County Department on Aging or any sponsoring agent. I hereby grant the Orange County Department on Aging permission to use any photographic likeness taken.
60. Disclaimer
    By typing your name below, you are signing "Orange County Department on Aging Waiver" electronically. You agree that you have read and understand the rules of conduct, and that your electronic signature is the legal equivalent of your manual signature on this application. NOTE: If you prefer not to sign electronically, please leave this form and visit the link at the right for a hardcopy.
61. Alternate Hardcopy
    Senior Center Programs
63. Signature
64. Date/Time
    Date/Time

    Date/Time
68. Wellness Program Waiver
    Please Note: Some wellness programs require 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, 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. I have informed the Orange County Department on Aging 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.
70. Disclaimer
    By typing your name below, you are signing "Orange County Department on Aging Wellness Program Waiver" electronically. You agree that you have read and understand the rules of conduct, and that your electronic signature is the legal equivalent of your manual signature on this application. If you prefer not to sign electronically, please leave this form and visit the link at the right for a hardcopy.
71. Alternate Hardcopy
    Senior Center Programs
73. Signature
74. Date/Time
    Date/Time

    Date/Time
78. THANK YOU!
80. Passmore Center
    POB 8181, 103 Meadowlands Dr., Hillsborough, NC 27278 / Phone: (919) 245-2015
82. Seymour Center
    2551 Homestead Rd., Chapel Hill, NC 27516 / Phone: 919-968-2070
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit Submit and Print

* indicates a required field