Senior Citizen Van Service Liability Form

Personal Information

Name Address Phone Date of Birth

Emergency Contact

Contact Name Contact Phone

Health Information

Medical Conditions or Allergies

Release of Liability

I, the undersigned, acknowledge and understand the risks involved in participating in the Senior Citizen Van Service. I release the organizers, volunteers, and partners from any liability for injury, loss, or damage while using this service.

I have read and agree to the terms above.