LIVING YOUNG PROGRAM REGISTRATION FORM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneDate of Birth *Email *Emergency Contact *Relationship to Emergency Contact *Emergency Contact Phone Number * Address Date Acknowledgment How did you find out about this program? *NewspaperSocial MediaFriend/Word of MouthPhoto and Liability Release I, hereby grant permission to the City of Clinton Therapeutic Recreation Department and its authorized representatives to take photographs and/or video recordings of me during my participation in the program. I understand that these photographs and/or video recordings may be used for promotional and informational purposes, including but not limited to program brochures, newsletters, websites, social media, and other promotional materials. I also understand that my name may be used in conjunction with these photographs and/or video recordings. I hereby release Clinton Therapeutic Recreation Department, its staff, volunteers, and any third parties acting under its authority, from any and all claims, liabilities, demands, actions, causes of action, costs, and expenses, including attorney's fees, which may arise out of or relate to the use of the photographs and/or video recordings, including any claim for compensation or invasion of privacy. I understand that participation in the Living Young exercise programs involves physical activity and certain risks. In consideration of being allowed to participate in this program, I agree to assume all risks, known and unknown, associated with my participation. I release Clinton Therapeutic Recreation Department, its staff, volunteers, and any third parties acting under its authority from any and all liability for injuries or damages that I may sustain while participating in the program. I acknowledge that I have carefully read and fully understand the contents of this Photo and Liability Release Form. I voluntarily agree to the terms and conditions outlined herein, and I understand that this release shall be binding upon me, my heirs, executors, administrators, and assigns. Photo & Liability Release Signature & Acknowledgment *I, the undersigned, acknowledge that I have carefully read and fully understand the Photo and Liability Release above. By checking this box and entering my name below, I voluntarily agree to all terms stated herein. I understand that this electronic acknowledgment, along with my typed name, serves as my legal signature.Participant Code of Conduct & Agreement The Clinton Therapeutic Recreation Department is committed to providing a safe, respectful, and inclusive environment for all participants, staff, volunteers, and visitors. Participation in our programs requires adherence to the following expectations: Participant Expectations All participants agree to: Treat staff, volunteers, and fellow participants with respect Follow all program rules, safety guidelines, and staff instructions Use appropriate language and behavior at all times Respect municipal facilities, equipment, and personal property Participate in a manner that does not disrupt or interfere with others Unacceptable Behavior The following behaviors are not permitted: Verbal, physical, or emotional harassment, threats, or intimidation Aggressive, unsafe, or disruptive behavior Use of profanity, abusive language, or inappropriate gestures Damage to facilities, equipment, or personal property Refusal to follow staff direction or program policies Caregiver / Guardian Responsibility (When applicable) Participants who require caregiver or guardian support must be accompanied by an individual capable of assisting with behavioral support and compliance with program expectations. Caregivers and guardians are expected to: Support adherence to the Code of Conduct Respond promptly if staff request assistance Model respectful and appropriate behavior Compliance & Disciplinary Action Failure to comply with this Code of Conduct may result in: Verbal warning Temporary removal from an activity Suspension from the program Restriction or denial of future program registration Serious or repeated violations may result in immediate removal from programs. The Department reserves the right to determine appropriate action based on the severity and frequency of the behavior. Code of Conduct Signature & Acknowledgment *I acknowledge that I have read, understand, and agree to comply with the Clinton Therapeutic Recreation Department Participant Code of Conduct. I understand that failure to comply may result in disciplinary action, including removal from programs and restriction of future participation. Checking this box and entering my name below serves as my electronic signature.Submit