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Senior Center Membership Application

  1. type in home phone number

  2. Type in cell phone if applies

  3. Month, day & year

  4. Type in home email address

  5. type in emergency contact name

  6. Type in how this person is related to you

  7. Type in your home phone number

  8. Type in their cell phone number or a second phone number

  9. Type in a second emergency contact name

  10. Type in how this person is related to you

  11. Type in your home phone number

  12. Type in cell phone or a second phone number

  13. Type in if Medical, Handicapped, or Activity use

  14. Type in any Drug Allergies, Food Allergies or Other Allergies

  15. Type in your Physician's Name

  16. Type in your physicians Phone number

  17. Type in Physician's address

  18. Terms and Conditions of Human Services Transportation

    1. Any medical or scheduled transport is the extent of the ride. Only exception and must be requested and approved by the office before the ride (if the driver has time) to stop for prescriptions after a Medical Transport if absolutely needed. 2. If parking fees apply to your medical transportation, it is YOUR RESPONSIBILITY to pay for it. 3. For the health, safety and the welfare of all passengers and drivers of the City Vehicles, the Director of the Broadview Heights Human Services Dept. may require that passengers bring an aide who is able to provide assistance to any passenger who utilizes transportation services provided by the City of Broadview Heights. 4. The Human Services Department reserves the right to refuse service due to illegal/inappropriate activity.

  19. Waiver and Release

    The undersigned does hereby waive, release and hold harmless and indemnify the City of Broadview Heights and the Broadview Heights Human Services Department, their organizers, officers, employees, agents and sponsors for any and all claims for damage of personal injury to me of loss of personal injury to me or loss of property that may be caused by any act or failure to act on the part of the City of Broadview Heights, the Broadview Heights Human Services Department property both real and personal and waive any and all specific notice of the existence of such dangerous conditions, if any. By participating in or attending any Human Services events and I agree to allow publication of any photograph taken of myself for advertising purposes. Please be advised that any information provided may be subject to public disclosure under the Ohio Open Records Law.

  20. Type in your full name

  21. Type in the date

  22. Leave This Blank:

  23. This field is not part of the form submission.