Poolesville Area Senior Center, Inc · Buddhist Temple Walk & Social

Your Information

Number Attending (between 1 and 8 please) *

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Your Name *

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Your Emergency Contact

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Attendee #2

Name of Attendee #2 *

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Emergency Contact for Attendee #2

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Attendee #3

Name of Attendee #3 *

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Emergency Contact for Attendee #3

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Attendee #4

Name of Attendee #4 *

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Emergency Contact for Attendee #4

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Attendee #5

Name of Attendee #5 *

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Emergency Contact for Attendee #5

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Attendee #6

Name of Attendee #6 *

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Phone for Attendee #6

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Emergency Contact for Attendee #6

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Attendee #7

Name of Attendee #7 *

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Email for Attendee #7

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Phone for Attendee #7

Address for Attendee #7

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Emergency Contact for Attendee #7

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Attendee #8

Name of Attendee #8 *

First Name

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Email for Attendee #8

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Phone for Attendee #8

Address for Attendee #8

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Emergency Contact for Attendee #8

Enter the name(s) and phone number(s) of your emergency contacts above.

Emergency Contacts

We like to keep name(s) and phone number(s) on file for anyone you'd like us to try to contact in the event of an emergency. If you haven't provided emergency contacts for any of the attendees, or just want to update that information, please check below and go back to supply the information with each attendee.

I'd like to enter Emergency Contact information.

Email List Policy

Each person for whom an email address is provided as part of an event registration is automatically placed on our email list for weekly updates about upcoming activities and other occassional announcements. The recipient of any of these emails may click the unsubscibe link at any point in time to be taken off the list and will not be added again with future registrations.

Waiver of Liability

We require that all participants in Poolesville Seniors activities agree to our Waiver of Liability policy (click here to read it).

Click to Accept Waiver of Liability Acceptance *

I have read and agree to the Poolesville Seniors Waiver of Liability policy for myself and for the others for which I am registering and will type my name below as a signature to indicate my acceptance.

Signature *

Please type your name as a signature.