SSA Registration

SENIOR SAFETY ACADEMY APPLICATION

* Indicates required field

Participant's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Advise us of any special needs: *

How did you hear about this program? *

Select Which Session You Want To Attend: *

Session 1: January 9, 16, 23 & 30 (Tuesdays) Session 2: February 5, 12, 19 & 26 (Wednesdays)

Hold Harmless *

As consideration for the opportunity to participate in the Academy, the Participant agrees to protect, hold harmless and indemnify the Drexel Heights Fire District, Pima Council on Aging, and Pima County, officers, agents, their employees and their volunteers, against all liabilities, claims, suits or demands for Injuries to person and/or property arising out of his/her participation in all of the events and activities of the Academy. Participant assumes all risks of injury.

Image Release Waiver *

I hereby grant permission to be photographed and/or videotaped while participating in Drexel Heights Fire District activities and/or to have any such work incorporating my image or original work I produce in conjunction with the activity published in association with Drexel Heights Fire District’s promotional and/or educational activities. I waive any right to compensation for such photographs, videotapes, images, and/or original work for the use or publication thereof.

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