Online Membership Form

Online Membership
Are you a: *
Gender *
Street Address *
Street Address
City
State/Province
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Section

Is Spouse A Member? *
I am: *
Marital Staus *
I currently live: *
Are you handicapped? *
Drug Allergies *
Will you need transportation to and from the activity center? *
Would you be willing to serve as a volunteer at the center? *

Primary Emergency Contact

Address *
Address
City
State/Province
Zip/Postal

Secondary Emergency Contact

Address
Address
City
State/Province
Zip/Postal

Section

I, as a participant of Broken Arrow Seniors, Inc., 1800 S. Main Broken Arrow, OK 74012, do voluntarily sign this waiver and assumption of risk. This includes any and all activities.

I am fully aware that there are certain risks and dangers associated with the facilities, instructions, equipment and/or activities that cannot be eliminated regardless of the care taken to avoid injuries and that these risks and dangers have been fully explained to me. I fully understand the risk and dangers involved. I assume the risks and dangers involved and agree to use my best judgment in undertaking these activities and agree to follow all safety instructions. I waive, release, covenant not to sue and agree to indemnify and hold harmless BASI from any claims, actions, suits, costs, expenses, damages or liabilities, including any attorney's fees for personal injury, property damage, accidents, illnesses, death, or any incidental damages that may arise from my use of the facilities or equipment or from my participation in the activities or receipt of instruction.

I am a competent adult and I assume these risks of my own free will. I have read this waiver and assumption of risk and I understand its terms. I understand that I am giving up substantial rights and I acknowledge that I intend by my agreement below that this be a complete and unconditional release of all liability to the greatest extent allowed by law.

Your photo may be taken during events. By agreeing, you grant Broken Arrow Seniors Inc. permission to use your photo for publicity purposes.

Agreement *