Adult Program Registration   ALL FIELDS IN THIS FORM ARE REQUIRED! Date of Registration (mm/dd/yyyy): First Name: Middle Name: Last Name: Street Address: Apt. # City: State:   Zip:    E-mail address: Cell Phone: Home Phone: Business Phone:   Sex: Male Female Race / Ethnicity (for funding purposes only) Please check one: Black Latino White Asian Native American Other Please specify Other: EMERGENCY CONTACTS In case of injury or illness, we must have updated names and numbers of alternate adults to contact. Name: Number: Relationship: Name: Number: Relationship: AGREEMENT As a condition of registration in the Goddard Riverside Community Center Adult Program, I confirm that all of the information given is correct. I agree to follow all program rules and regulations. Goddard Riverside Community Center is not responsible for any lost, damaged or stolen property. WAIVER: I hereby authorize Goddard Riverside Community Center to photograph and record me for any and all promotional purposes in connection with Goddard Riverside Community Center Adult Program. I agree to hold Goddard Riverside Community Center harmless from any liability arising out of photographs or recordings and waive any compensation for pictures, printed works or audio/video products of or by me. MEDICAL AUTHORIZATION: IN the event of an emergency and after every attempt has been made to contact emergency contacts above, I hereby give permission for the agency, Goddard Riverside Community Center, to get medical treatment for me. I further authorize the doctor or the hospital to which I may be brought, and whomever they may designate as their assistant, to perform any emergency procedure or operations to me during my attendance in the Goddard Riverside Community Center Adult Program. HEALTH CONDITION: Please indicate any health condition, e.g. allergies, asthma, medication taken or special restrictions on your participation or that will help us in case of any medical emergency.   Please type your full name as signature: Date: