Participant Information Form

  • Date Format: MM slash DD slash YYYY
  • If Different than Home phone
  • Emergency Contact Information

  • Program Choices

  • Public Relations Statement

    to allow Eastern Area Agency on Aging to use my name or likeness (photo) or audio for any purposes they see fit in their Public Relations/Marketing/Social Media materials, including but not limited to posting on EAAA's website, newspapers, and television advertisements. EAAA retains sole copyright to said likeness and may use it in any form now and in the future. I understand I will receive no monetary gain from this use.
  • Release

    By typing your name below you are agreeing to Eastern Area Agency on Agings Release Policy.
  • hereby acknowledge that all of theabove information is true. I release the Eastern Area Agency on Aging and all of its agents from all liability for any accident, injury or damages of any kind to persons or property that might occur while I participate in any Eastern Area Agency on Aging programs.