Senior Confidential Information Form

Race/Ethnicity

Emergency Information

Emergency Contact Name

Relationship to Senior

Facility Purpose

By checking this box, I understand that the Clovis Senior Center is an independent participation facility and not an adult day care facility or an assisted living facility.

Photography permission

By checking this box, I consent to be photographed by a representative of the Clovis Senior Activity Center for the purposes of Senior Activity Center publications. (i.e. website, newsletter called NEWSWAGON), and program events.

Monthly Newsletter Options

I would like the monthly newsletter mailed to my home address I would like the monthly newsletter emailed to my email address above I would like to pick up the monthly newsletter at the Senior Activity Center I do not want the newsletter at this time

Code of Conduct

By checking this box, I verify that I have reviewed and agree to abide by the Clovis Senior Center Code of Conduct policy.