TURLOCK SENIOR CITIZENS

MEMBERSHIP FORM

Date: ____________________

囗 Male     囗 Female

Name: _____________________________________________________________

Address:_____________________________________________________________

City: ___________________________

Zip:___________________________

Home Phone: ___________________

Cell Phone: ___________________

eMail Address: ________________________________________________________

Check this box to have your address, phone, and email excluded from the directory.

Emergency Contact #1

Name: _________________________________________________________________

Relationship: ____________________________________________________________

Home Phone: ___________________________________________________________

Work Phone: ____________________________________________________________

Cell Phone: _____________________________________________________________

Emergency Contact #2

Name: _________________________________________________________________

Relationship: ____________________________________________________________

Home Phone: ___________________________________________________________

Work Phone: ____________________________________________________________

Cell Phone: _____________________________________________________________

Please sign and date the back of this form.

STATEMENT OF INFORMED CONSENT, INDEMNITY, RELEASE, AND WAIVER TO PARTICIPATE IN
TURLOCK SENIOR CITIZENS GROUP

I hereby expressly waive and release all claims and causes of action I now have or in the future may have against the City of Turlock based on, or related directly or indirectly to, my voluntary participation in Turlock Senior Citizens Group activities

To the extent of such waiver and release, I expressly waive my rights, if any, under California Civil Code Section 1542 which provides:

“A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR.”

To the fullest extent permitted by law, I agree to indemnify, defend, and hold harmless the City of Turlock, its officers, agents, and employees from and against all claims, damages, losses and expenses, including but not limited to attorney fees, arising out of, resulting from, or in any manner related to my participation in Turlock Senior Citizens Group activities.

Date: _________________

Member Signature: _______________________________________________________

Print Name: _____________________________________________________________