Membership

Your Name *

First Name

Last Name

Your Date of birth *

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Your Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Phone Number *

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Are you a new member or renewing your membership? *

New Member

Renewing

Emergency Contact #1's Name *

First Name

Last Name

Emergency Contact #1's Phone Number *

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Emergency Contact #2's Name

First Name

Last Name

Emergency Contact #2's Phone Number

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Waiver Acknowledgement *

I, a participant in activities, programs, and trips sponsored by the Madison Senior Center, a community service of Madison Village, Madison Township, and Lake County Commissioners, do hereby acknowledge that I am voluntarily participating. I recognize that in any activity, program or trip, there are certain risks of injury to myself. I declare that my health and physical condition is adequate to meet the physical requirements of activities, programs, and trips in which I participate. I agree to hold The village of Madison, Madison Township, and the Madison Senior Center, their respective agents, representatives, instructors, volunteers and participating companies and agencies harmless and indemnify them from any and all claims for damages to persons or property caused by myself or for any and all injuries sustained by me during my activities, programs, and trips. I agree to obey and abide by the rules and regulations of the Madison Senior Center, Village of Madison, and Madison Township and to follow said instruction of same. I further acknowledge that I am becoming a registered member of the Madison Senior Center in reliance upon this waiver of liability. By selecting "I Agree", I am agreeing to the terms and rules above.

I Agree

Today's Date *

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DD

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