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OMA Registration - Spring Session 2023 - Fridays
Fridays, April 14 - June 2, 10:30-11:30 am
Enroll my family in OMA!
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Yes!
Participant Name
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First Name
Last Name
Caregiver Name
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First Name
Last Name
Caregiver Email
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Verify Email
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Caregiver Home Phone
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Caregiver Mobile Phone
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Address
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Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Emergency Contact (other than Caregiver)
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First Name
Last Name
Emergency Contact Phone
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Please tell us about the Participant
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To better prepare our volunteers to work with your loved one, we would like to know about the participant’s fine motor skills, communication skills, physical limitations, and the comfort level outside of their home.
Photo Release
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I hereby grant and authorize The Cultural Arts Center at Glen Allen the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me and the OMA participant to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely unless I otherwise revoke said authorization in writing.
I agree
I do not agree