Pick Up Location *

Santa Monica

Baldwin Hills

I will drive myself

Name *

First Name

Last Name

CELL Phone *

(###)

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HOME Phone *

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Membership *

Member

Non-Member

Terms of Service *

Payment in full is required to reserve space. No refunds for cancellations. I hereby consent to the photographing, recording and reproduction in any other manner (including the use of film, video and audiotapes) of the likeness, voice, and/or activities as a member of WISE & Healthy Aging programs, and further authorize WISE & Healthy Aging, its agents or assign, to make unlimited use of such reproduction, including but not limited to broadcasting of the reproductions over radio, television, print and/or the internet. I do understand that I will not receive any monetary compensation now or in the future for participating. I do hereby release and hold harmless WISE & Heathy Aging, its officers, and employees from any claims. In consideration of my participation in the programming/activities for which I have registered, I waive all claims for damages for death, personal injury, or property damage that may occur as a result of engaging in that programming or activity. This discharges in advance WISE & Healthy Aging, its employees, and other agents from liability even though that liability may arise out of their negligence. I know that the programming/activities involve a risk of accidents, and I willingly assume the risk. For physical activities that I sign up for, I take responsibility that I have cleared with my physician my ability to participate. This waiver, release and assumption of risk are binding on my heirs and assignees. For any outings/excursions that I attend, I am aware that such trips may involve transportation, overnight accommodations, entertainment, meals, amusement facilities, tours, shopping areas, and exposure to such elements as heat, rain, cold, and other unforeseen hazards. If I require emergency medical treatment for any reason while participating in these events, I authorize WISE & Healthy Aging staff to provide necessary first aid and, if needed, to arrange for emergency transportation and admission to any licensed medical facility in the event I am unable to admit myself. I understand that emergency medical services are at my expense. I further understand that if I am not on time at specified departures for trips (going to and/or returning from), that I will be responsible for making my own arrangements thereafter, at my own expense.

I AGREE to the Terms of Service

Date *

MM

DD

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