Community Action House Program Registration / Inscripción al Programa de Casa de Acción Comunitaria
Sign in to Google to save your progress. Learn more
First Name / Nombre 
Last Name / Apellido
Date of Birth (mm/dd/yyyy) / Fecha de Nacimiento
Phone (xxx-xxx-xxxx) / Número de Teléfono
Email / Correo Electrónico
Which class are you signing up for?  / ¿Por cuáles clases quiere registrarse? 
Clear selection
Preferred Language / Idioma Preferida
Please list any food allergies or restrictions / Por favor describa aquí si tiene alguna alergia alimentaria.
I, the Participant, do hereby release and forever discharge and hold harmless Community Action House and their respective directors, officers, trustees, employees, volunteers and agents (collectively, the “Released Parties”) and their successors. Including any and all liability, claims and demands which I or my heirs, assigns, next of kin or legal representatives may have or which may hereinafter accrue with respect to any bodily injury, personal injury, illness, death or property damage which arise or may hereafter arise from or is in any way related to my Activities with any of the Released Parties, whether caused wholly or in part by the simple negligence, fault or other misconduct, other than intentional or grossly negligent conduct, of any of the Released Parties or of other volunteers. I understand and acknowledge that by this Release I knowingly assume the risk of injury, harm and loss associated with the Activities. I also understand that the Released Parties do not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance in the event of injury, illness, death or property damage. 

I understand that it is my responsibility to notify the appropriate person in the workplace or event host(s) of emergency medical information and have informed the instructor of ANY food allergies/or dietary restrictions. I, the Participant, do hereby grant and convey unto Community Action House, all right, title and interest in any and all photographs and video or audio recordings of or including my image or voice, made by any of the Released Parties during my Activities with the Released Parties, including, but not limited to, the right to use such photographs or recordings for any purpose and to any royalties, proceeds or other benefits derived from them.

/

Yo, el Participante, por la presente comunico y exonero para siempre Community Action House y sus funcionarios, directores, agentes, empleados, voluntarios, aseguradores y representantes (“Liberados”) no serán responsables de ninguna lesión personal, daño a la propiedad, discapacidad, muerte, enfermedad o enfermedad en la que incurra yo, mis familiares, dependientes o invitados, incluidos menores de edad, sin embargo, incluyendo, entre otros, la negligencia de los Liberados o otros participantes. Entiendo que seré el único responsable de cualquier pérdida o daño, incluyendo lesiones personales, daños a la propiedad, discapacidad, muerte, enfermedad o enfermedad sufrida por la participación en las actividades. 

Entiendo que es mi responsabilidad notificar a la persona correspondiente en el lugar de trabajo o al anfitrión(es) del evento sobre información médica de emergencia y he informado al instructor sobre CUALQUIER alergia alimentaria o restricción dietética. Yo, el Participante, consiento a dejar al Community Action House, a sacar y reproducir fotografías, audio, y grabaciones de video de mi persona sin pago u otra consideración. Consiento y estoy de acuerdo que dichas fotografías, imágenes, grabaciones, reproducciones son propiedad exclusiva de CAH. Esto incluye cualquier declaración legal o demanda por beneficio, confederación o dinero obtenido como resultado del uso o la venta de estas fotografías, imágenes, grabaciones, o reproducciones de mi aspecto o voz.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Community Action House.

Does this form look suspicious? Report

Google Forms