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Westend Seniors Activity Centre              
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1. Are there medical conditions that the staff should note in case of emergency at the Centre?
2. For statistical purposes for our funding please state whether you live alone or with others.
3. 3. Do you have interests, hobbies or acquired skills? If so, what are your areas of interest?
Are you willing to share these with others by assisting with projects at the centre? Yes No Instructing others? Yes No
5. Past Employer
Do you have any interest in Volunteering a few hours a month to the Centre? Yes No Not Sure If yes, please indicate which areas you would be interested in helping with:
Program Waiver I ____________________________________________ recognize that the activities of the club/program I will be participating in may have some inherent risks. I knowingly and voluntarily assume the risks of engaging in this activity. I acknowledge that it is my responsibility to be aware of the risks associated with the activity and to safeguard my person by ensuring: 1. That I am physically able/capable of the activity. 2. That I exercise safety measures appropriate to the activity, and 3. That I do not participate beyond my capabilities. I understand that although Westend Seniors Activity Centre endeavors to provide competent leadership and instruction for the club/program I am joining, it can not warrant in anyway, their competency or professionalism. I acknowledge that Westend Seniors Activity Centre organizes activities only and does not necessarily possess any special skill or knowledge in relation to any of the activities. I hereby release Westend Seniors Activity Centre from any liability arising out of my participation.
Name (print)______________________________________ Phone ____________________
Address _________________________________________
Signed ___________________________________________ Date______________________ This Waiver is effective for the duration of membership with Westend Seniors Activity Centre
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