Membership Registration Form

    Member Information

    Choose the location:

    Ethnic Group (Optional, but does assist with potential funding):

    Emergency Contact

    I agree that Dorchester Seniors, Inc. will not be held liable for injuries or other loss which may occur as a result of my participation in Center activities, programs which includes the fitness room and fitness equipment and that I voluntarily assume the risk of any loss, injury or damage to person or property, which in any way arises out of participation in said activity.

    Further, I agree to RELEASE, INDEMNIFY, AND HOLD HARMLESS Dorchester Seniors, Inc. from any and all claims, actions, demands, rights, judgments or expenses arising from or by reason of any and all known or unknown damages, claims or actions arising from participation in the above-described activity

    I hereby give permission for the Dorchester Seniors, Inc. to arrange for transportation to a hospital in the event of any injury, although I understand that Dorchester Seniors, Inc. assumes no responsibility to do so. I accept full financial responsibility for payment of any and all medical services rendered.

    I hereby give Dorchester Seniors, Inc. permission to use my photograph for purposes of public relations. I agree the above information may be released in Emergency Situations ONLY

    My signature is receipt that I have received a copy of the Member Handbook and do hereby agree to abide by its rules.

    Your Signature: