Required fields are marked with asterisks (*)

GM Seniors Active Living Program Registration Form

Membership is FREE!

Requirements: You must be age 55+ and a resident of Greater Madawaska.

Participant Information:

Name:

Date of Birth:

Address:

Phone Number:

Email Address:

Name:

Relationship:

Phone Number:

Please check the activities you are interested in:

Fitness Classes

Arts & Crafts

Social Events

Educational Workshops

Other (please specify below)

Other:

Do you have any health conditions that we should be aware of?

Do you require any accessibility accommodations?

I understand that participation in the Seniors Active Living Program is voluntary and I assume responsibility for any risks involved.

I consent to receiving updates and notifications about program activities.

Signature:

Clear

Date: