First Name *
Last Name *
Zip Code *
Phone Number *
Email Address *
Date of Birth *
Name of Spouse
We occasionally take pictures of members at our events. May we use your photo in advertising, on our website or in Social Media? Please answer yes or no in the next field.
Name Emergency Contact 1 *
Phone Number Emergency Contact 1 *
Relationship to Emergency Contact 1 *
Second Emergency Contact:
Name of Emergency Contact 2
Phone Number Emergency Contact 2
Relationship to Emergency Contact 2
Hold Harmless Agreement
To the fullest extent permitted by law, while attending and, or participating in programs or activities offered by the Town of Fairfield, Bigelow Center, I, for myself, my heirs, successors, executors, administrators and assigns, knowingly and voluntarily do hereby RELEASE, INDEMNIFY and HOLD HARMLESS the Town of Fairfield and the Bigelow Center, their officers, employees and agents from and against any and all losses, claims, costs, damages, judgments, suits and expenses, including reasonable attorney’s fees arising from, alleged to arise from, or resulting in personal injury to me, any third party, or my property and from and against any claims of injuries or damages that I may cause to any person or property. I do understand that if I am injured while participating in any program or activity, I am solely responsible for any and all costs that I may cause or incur, including medical treatment. In addition, the undersigned understands and acknowledges that the novel coronavirus (“COVID-19”) has been declared a worldwide pandemic by the World Health Organization and is extremely contagious. By signing this agreement, the undersigned acknowledges the contagious nature of COVID-19 and voluntarily assumes the risk that the undersigned may be exposed to and/or infected by COVID-19 at any point during the undersigned’s utilization of Bigelow Center services, programs and/or activities and that such exposure or infection may result in personal injury, illness, permanent disability and/or death
Member Code of Conduct
The Bigelow Center for Senior Activities is dedicated to promoting a dignified, healthy quality of life for older adults by advocating for vital services, providing opportunities to develop meaningful fellowship, offering lifelong learning activities, recognizing the continued and varied accomplishments of older adults, and being an accessible and trusted community resource. * All Town of Fairfield Facility Policies as set by the Fairfield Health Department and Town of Fairfield apply to the Bigelow Center. In times of health concerns, appropriate facemasks may be required and hands must be sanitized upon entry. Those who refuse will not be permitted to enter the building. * Treat everyone with respect. * The use of abusive, intimidating, threatening, or harassing language strictly prohibited. * Fighting, physical abuse, challenging others to fight, destroying or damaging property and other disruptive, intimidating or harassing behaviors are strictly prohibited. * Alcohol or illegal drugs shall not be brought to the Center or Center grounds. Anyone under the influence of alcohol or illegal drugs will be asked to leave the Center. * Weapons of any kind are not permitted on the premises. * The Center does not provide sleeping accommodations. Lying outstretched or sleeping on the furniture or the floor is not allowed. * Proper shoes and clothing must be worn at all times. * No solicitation or sales of goods or services by an individual, participant or group are allowed. * Participants who cause an unreasonably loud noise that is disturbing or annoying may be asked to leave the building. * Please refrain from any PDA (public display of affection) which includes but is not limited to: sexually implicit dancing, kissing, groping and lap sitting General Facility Rules * Participants must complete and submit a registration form annually and scan card/sign-in at each visit. * Participants are not allowed in staff areas (kitchen, offices, closets) without staff permission. * Service Animals (as defined by federal and state law) may enter the Center, must be restrained, and under the supervision of their companion or owner at all times. * Animals may not be left unattended outside the Center. * Community phone use is limited to local calls for emergencies. * Restrooms shall not be used for bathing, shaving, or washing clothes. * Smoking is strictly prohibited in the building or on the premises. * Personal belongings must not be left unattended. * Any minor visiting in the Center must be signed in and supervised by his/her guardian at all times. Minors who are volunteering must have parental approval and be under the supervision of designated staff, teacher or parent at all times. * All senior center participants under 60 years of age who participate in the lunch program shall pay $13.00 per meal and wait until eligible seniors have been served. * Surveys, photographs, or video recording in the Center require prior written permission of the staff. Release forms are required.
Agreement of Participant
I have read and agree to follow the Bigelow Center for Senior Activities Member Code of Conduct and Hold Harmless Agreement. DISCLAIMER: By checking this box and typing your name below, you are signing this membership form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Your Full Name *