HomeParticipant Information Form

Participant Information Form

"*" indicates required fields

Date
Name*
Race (Optional)
Ethnicity (Optional)
Home Address*
Is your home address the same as your mailing address?
Mailing Address (If different than Home Address)
If Different than Home phone
My preferred phone number is :
I would like to receive EAAA's Newsletter

Emergency Contact Information

Emergency Contact #1 Name*

Program Information

Public Media Relations Statement (optional)

to release and hold harmless Eastern Area Agency on Aging from any and all liability, claims, demands, costs, and damages of any kind, including personal injury, bodily injury, illness, property damage, loss or death. I understand that by signing this release I assume the risk of injury, harm, damage, and loss associated with the Activities. I also understand that the agency does not assume any responsibility for provision of financial assistance including medical, health or disability insurance in the event of injury, illness, or property damage. I, acknowledge that I have received the Durgin Center Code of Conduct. By accepting the Durgin Center Code of Conduct and acknowledging its receipt, I agree to follow the policies and procedures, and understand that any breach of this agreement may result in my dismissal.*
to release and hold harmless Eastern Area Agency on Aging from any and all liability, claims, demands, costs, and damages of any kind, including personal injury, bodily injury, illness, property damage, loss or death. I understand that by signing this release I assume the risk of injury, harm, damage, and loss associated with the Activities. I also understand that the agency does not assume any responsibility for provision of financial assistance including medical, health or disability insurance in the event of injury, illness, or property damage. I, acknowledge that I have received the Durgin Center Code of Conduct. By accepting the Durgin Center Code of Conduct and acknowledging its receipt, I agree to follow the policies and procedures, and understand that any breach of this agreement may result in my dismissal.

Release and Waiver

By typing your name below you are agreeing to Eastern Area Agency on Agings Release Policy.
I,*
do release and hold harmless Eastern Area Agency on Aging from any and all liability, claims, demands, costs, and damages of any kind, including personal injury, bodily injury, illness, property damage, loss or death. I understand that by signing this release I assume the risk of injury, harm, damage, and loss associated with the Activities. I also understand that the agency does not assume any responsibility for provision of financial assistance including medical, health or disability insurance in the event of injury, illness, or property damage. I, acknowledge that I have received the Durgin Center Code of Conduct. By accepting the Durgin Center Code of Conduct and acknowledging its receipt, I agree to follow the policies and procedures, and understand that any breach of this agreement may result in my dismissal.

Durgin Center Code of Conduct

Eastern Area Agency on Aging requires consumers and visitors to be safe, to show respect for others, and to show respect for the facility while at the Durgin Center and participating in programming.  The Durgin Center is designed to be a welcoming space to meet the needs of the Eastern Maine community.

While at the Durgin Center consumers and visitors are prohibited from:

  • Engaging in any illegal activity
  • Smoking any substance, or use tobacco, e-cigarettes
  • Consuming alcohol or illegal substances
  • Possessing weapons
  • Creating a public disturbance or use of obscene and/or abusive language, gestures or acts
  • Engaging in harassment or threatening behavior and inappropriate sexual, physical, or verbal contact towards anyone at the Durgin Center, including staff and volunteers
  • Soliciting
  • Damaging or defacing any materials or tampering with or displacing furniture or equipment
  • Bringing pets, other than service animals or animals used for Eastern Area Agency on Aging programs, into the building; all animals must be under control at all times.
  • Any other behavior deemed in conflict with the agency’s mission as determined by the Executive Director or leadership staff

The agency reserves the right to take disciplinary action if consumers and visitors are in violation of the agency’s policies and procedures.