Date of Birth ______/______/______
Last Name __________________________________ M [ ] F [ ]
First Name __________________________________
Address _____________________________________ City ____________________________ Zip ________________
Home
Phone (_____)_______________________
Cell Phone (_____)_______________________ *Ok to Text Updates ___yes ___ no Mobile Carrier____________
*ActiveNet will allow us to send text messages regarding facility closures, program updates, etc.
Email _______________________________________
Emergency Contact:
Name _______________________________________ Phone (____)___________________________
Relationship to Emergency Contact_____________________
Medical Alert_________________________________________________
How did you hear about the Senior/Community Center? (please choose one)
1.Referred By: ________________________ 2. Internet 3. Flyer/ Brochure
4.Magazine 5. Newspaper 6. Other
COPPELL SENIOR/COMMUNITY CENTER AT
G
RAPEVINE SPRINGS ACTIVITY RELEASE FORM
I understand that there are risks involved in the programs/memberships which are
sponsored by the City of Coppell Parks and Recreation department. I accept full re-
sponsibility for any injury or accident to myself, spouse or any of my dependents. I
hereby release, indemnify and hold harmless the City of Coppell, the Parks and Rec-
reation department, their agents, officers, employees, contractors, instructors and any
person acting on behalf of the city for any damages, causes of action of any kind what-
soever, statutory or otherwise, for personal injury, including death, property damage
and lawsuits and judgments, including court costs, expenses and attorney fees, and all
other expenses that might arise hereafter, directly or indirectly in connection with my
participation or the participation of my spouse or dependents in any of the programs/
memberships listed. I do hereby grant and give these groups the right to use my or my
child’s photograph or image with or without my or my child’s name, both single and
in conjunction with other persons or objects, for the purpose of advertising, private or
public presentations, publicity, and promotion relating thereto.
________________________ ____________________________
SIGNATURE OF PARTICIPANT: DATE
_____ (Initial) Cardholders and visitors must abide by rules and regulations of the City of Coppell Senior/Community
Center or privileges may be revoked.
_____ (Initial) Facility usage cards or payment receipts are required for entry.
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