This Participant Form is intended for individuals who are new to the Tallahassee Senior Center. If you have previously completed a paper version of this form, you do not need to submit it again.

Name(Required)
Birth Date(Required)
Address(Required)

Emergency Contacts:

Previous Participation

What Senior Center and/or Leon County Senior Outreach group have you already participated in before completion of a Participant Application form:

Some Tallahassee Senior Services programs are funded in part by grant dollars. In order to receive this funding, we are required to report the following information that we are requesting. At no time are participants' names released or given to any agency, funding source, or outside party. Only the aggregate data is reported.
Ethnicity:
Race: (check only 1 of the following)
Gender(Required)
If FEMALE, I am head of my household?
Please enter a number greater than or equal to 1.
Do you qualify for a handicap sticker or hanging sign/placard?

Release of Liability

Please read and check the box.
By checking the box below, I hereby agree and acknowledge that I am voluntarily participating in activities, which may include without limitation, health screenings, physical activities and educational classes, made available to me through the Tallahassee Senior Center (“Center”) and the Tallahassee Senior Center Foundation (“Foundation”).  In consideration for allowing me to participate in such activities, I, on behalf of myself, my heirs, executors and administrators, hereby state that I am of sound mind and hereby waive and release any and all rights and claims for damages that I may now or hereafter have against the City of Tallahassee,  the Center, or the Foundation, and their officials, employees and agents, for any and all injuries or illnesses suffered by me and which arise from or are related in any way to travel to and from any activity site or participation in, receipt of, or rendition of any activity.  I understand that some health care related services are provided by independent third-party entities or agencies and the agencies, entities, and individuals providing these health services are neither employed by, under contract with, selected by, screened by, or endorsed by the City of Tallahassee, the Center or the Foundation, or the officials or employees of either, and that such services should not substitute for the advice of my primary care physician. (Required)