Colley Senior Complex 715 Elm Street Troy, Alabama 36081 Telephone: 334-808-8500 Fax: 334-808-8549 NAME: ________________________________________________________________ ADDRESS: _____________________________ TELEPHONE: __________________ CITY: _____________________ STATE: _______________ ZIP: ________________ EMAIL ADDRESS: ______________________________________________________ DATE OF BIRTH: __________________________________ AGE: _______________ IN CASE OF EMERGENCY CONTACT: _____________________________________ DOCTOR: _______________________________ PHONE: _______________________ SPECIAL HEALTH CONDITIONS __________________________________________ Would be interested in volunteering? _________________________________________ Check the activities below that you might be interested in: ______ Aerobics ______ Low Impact Exercise ______ Stained Glass ______ Bible Study ______ Movies ______ Stretching ______ Bridge ______ Painting ______ Table Games ______ Ceramics ______ Pottery ______ Tai Chi ______ Computer ______ Quilting ______ Trips/Tours ______ Clogging ______ Sewing ______ TOPS ______ Crochet ______ Shirt Painting ______ Water Aerobics ______ Gardening ______ Singing ______ Workshops (Art) ______ Line Dancing ______ Smocking ______ Yoga Other interests: __________________________________________________________ WAIVER OF RESPONSIBILITY As a participant in this recreational or social activity, I agree to abide by all the rules, regulations and policies set forth by the Colley Senior Complex. I understand that the activities and services I wish to participate in may have an element of hazard or inherent danger, and I take full responsibility for my actions and physical condition. I agree to identify and hold the Colley Senior Complex and their employees, volunteers, representatives, successors and assigns, harmless from any liability, loss, cost, or expense (including but not limited to attorney’s fees, medical and ambulance costs) that may be incurred because of my participation in the Colley Senior Complex activities. In case of emergency, I give my permission for the use of ambulance services and medical treatment. It is agreed that this form shall be considered valid until canceled or changed in writing by the undersigned participant. My signature confirms I have read and understand the information contained above. SIGNATURE: _____________________________ DATE: _______________________ * Always check classes and happenings on the clip board in lobby. Be sure to sign the activity sheets.