Senior Center Membership Application | Gold Country Senior Services

Type of Membership(Required)

Individual Annual ($50)

Couple Annual ($75)

Family Annual, up to four people ($125)

Does your family consist of 3 or 4 people?(Required)

Member #1

Name(Required)

First Last

Enter Email Confirm Email

Phone(Required)

Member #1: Release of Liability and Assumption of Risk Agreement, Photo Release

I agree to the liability release below

I hereby release the Gold Country Community Services California, its representatives,
employees, volunteers, agents, assigns, officers, agents, and employees from any and all
claims, obligations, choices of action, and liability of any kind, arising out of or connected
with my participation in classes or activities at the Senior Center and entry to and use of any
facilities or equipment at the Senior Center. The consideration for this release is my
participation in classes or activities at the Senior Center and entry to and use of any facilities
or equipment at the Senior Center. This release is intended as a full and complete release
covering any possible claims, injuries or harm, contingent or otherwise, involving personal
injury or property damage which may arise in connection with my participation in classes or
activities at the Senior Center and entry to and use of any facilities or equipment at the
Senior Center. I HEREBY RELEASE, DISCHARGE, AND HOLD HARMLESS ALL OF THE ENTITIES
OR PERSONS MENTIONED ABOVE WHO MIGHT OTHERWISE BE LIABLE TO ME, OR MY HEIRS,
PERSONAL REPRESENTATIVES, RELATIVES, SPOUSE, AND/OR ASSIGNS.

I grant to Gold Country Senior Services, Inc., the permission to take statements from and/or
photographs of me and my family in connection with the below-identified activity &
location. I authorize Gold Country Senior Services, Inc., its assigns and transferees to
copyright, use and publish the same in print and/or electronically. I agree that Gold Country
Senior Services, Inc. may use such photographs of me with or without my name and for any
lawful purpose, including for example such purposes as publicity, illustration, advertising,
and Web content.

Member #2

Name(Required)

First Last

Member #2: Release of Liability and Assumption of Risk Agreement(Required)

I agree to the liability release below

Member #2: Photo Release(Required)

I agree to the photo release below

I grant to Gold Country Senior Services, Inc., the permission to take statements from and/or
photographs of me and my family in connection with the below-identified activity &
location. I authorize Gold Country Senior Services, Inc., its assigns and transferees to
copyright, use and publish the same in print and/or electronically. I agree that Gold Country
Senior Services, Inc. may use such photographs of me with or without my name and for any
lawful purpose, including for example such purposes as publicity, illustration, advertising,
and Web content.

Member #3

Name(Required)

First Last

Member #3: Release of Liability and Assumption of Risk Agreement(Required)

I agree to the liability release below

Member #3: Photo Release(Required)

I agree to the photo release below

Member #4

Name(Required)

First Last

Member #4: Release of Liability and Assumption of Risk Agreement(Required)

I agree to the liability release below

Member #4: Photo Release(Required)

I agree to the photo release below

Home Address

Street Address City State ZIP Code

Help a local low-income senior(Required)

Total

Credit Card(Required)

Scholarship

I would like to be considered for a scholarship to cover my membership fee.

By checking this box, I attest that my income is under $14,580/year for a oneperson household or $19,720 for a two-person household.