Fields marked with an * are required
Demographic Information (Helpful & Optional):
Do you identify as any of the following?
I am interested in:
By checking a scholarship box I attest that I make less than $1400 monthly gross income per single household or less than $1900 monthly gross income for a two-person household and will notify Lifelong if my income changes to above that income level.
I would like a scholarship for the following:
Acknowledgement of Risk and Liability
I hereby apply to participate in activities (classes, programs, events, and trips) to be conducted by LIFELONG and acknowledge the following: I fully understand and acknowledge that there are inherent risks and dangers in my participation in the activities and my participation in said activities and use of any equipment or materials related to such activities may result in my injury, illness or death and damage to or loss of my personal property. I understand other participations, accidents, forces of nature or other causes may cause these risks and dangers and I hereby fully acknowledge and accept these risks and dangers. I am in good health and I am able to participate in any strenuous physical activity associated therewith. I understand and agree it is my responsibility to get any medical clearance or approval from my medical health professional to participate.
I herewith release, forever discharge and waive any right of recovery or subrogation against LIFELONG, its officers, directors, employees and volunteers from any and all liability whatsoever for any illness or injury, including death or damage to or loss of my personal property that I may sustain while I am participating in this program. This shall be binding on my heirs, successors, assigns, administrators and executors. Any claims or disputes arising out of my participation in the activity shall first be submitted to arbitration and/or be venued in the Supreme Court of the State of New York of Tompkins County.
I HAVE READ THE ABOVE OR I ACKNOWLEDGE, THAT I HAVE HAD THIS DOCUMENT READ TO ME AT MY REQUEST AND I AGREE IT IS MY INTENTION TO PARTICIPATE IN ACTIVITIES AND I UNDERSTAND AND ACCEPT ALL RISKS INVOLVED.
For good and valuable consideration herein acknowledged as received, I hereby grant Tompkins County Senior Citizens Council, Inc. (dba Lifelong), its legal representatives and assigns, those for whom said corporation is acting, and those acting with its authority and permission, the absolute right to copyright and use, reuse, publish and republish any or all video/audio tapes, photographs, negatives, or prints taken of me by representatives of said corporation, without restriction as to changes or alterations from time to time, in conjunction with my name or a fictitious name in any medium for art, advertising, trade, or any other purpose whatsoever. I hereby waive any right that I may have to inspect or approve the finished product or products or advertising copy or printed or electronic matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge and agree to save harmless Tompkins County Senior Citizens Council, Inc., its legal representatives or assigns, and all persons acting under its permission or authority or those for whom it is acting, from any liability by virtue of any blurring, distortion, alteration, optical/audio illusion, or use in composite form that may occur or be produced in the creation and production of any of these materials. I hereby warrant I am of full age and have every right to contract in the above regard. I state further that I have read the above authorization, release and agreement, prior to its execution, and I am fully familiar with the contents thereof.
After clicking the "Submit" button below, this information will be sent to Lifelong and you will be taken to the Paypal Checkout page to pay the Membership fee of $40. If you do not have a Paypal account you can still use your credit card to pay by clicking "Don't have a Paypal account?" on the checkout page to pay securely using a major credit card.