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Membership Form
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Name
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First
Last
Date of Birth (mm/dd/yyyy)
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Gender
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Male
Female
Street Address
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City
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State
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Zip
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Home Phone
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Cell Phone
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Email
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I Am
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Caucasian
Hispanic
African American
Native America
Asian
Other
Is Spouse a Member?
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Yes
No
Marital Status
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Single
Married
Widowed
Divorced
Other
I Currently Live
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Alone
With My Spouse
With My Children
Assisted
Other
Are You Handicapped?
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Yes
No
Drug Allergies?
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Yes
No
Daily Medications
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If Yes, Please List Drug Allergies
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Known Health Issues
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Doctor's Name
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Will You Need Transportation to and from the Activity Center?
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Yes
No
Would You Be Willing to Serve as a Volunteer at the Center?
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Yes
No
Frequency
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How Did You Hear About Us?
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Primary Emergency Contact
Name
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First
Last
Relation
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Phone
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Street Address
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City
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State
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Zip/Postal
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Secondary Emergency Contact
Name
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First
Last
Relation
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Phone
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Street Address
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City
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State
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Zip/Postal
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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.
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Yes, I Agree to the Terms Stated Above.
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Welcome
Medicare Fair
Calendar
Nutrition
Newsletter
Membership
New Member
Renewing Member
Membership Payment
Events
Contact
Blog
