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Oconee County Senior Center Registration Form

  1. Oconee County Senior Center

    VERY IMPORTANT: Please be sure your form is completed and signed in all required spots so that the Senior Center is able to receive needed funding from federal and state sources. If you have questions, please contact Angela Helwig at 706-769-3979.

  2. Senior Center Registration Form

    Please fill out entire form and click on submit

  3. Please type in name and a contact phone number.

  4. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  5. By signing, you acknowledge that you have read and understand the Oconee County Senior Center Policies and Guidelines as stated in the above linked document.

  6. Emergency Contact #1

  7. Emergency Contact #2

  8. Additional Member Information

  9. Are you a veteran?*

  10. Living Situation*

  11. Attended the Senior Center before?*

  12. Services from other agencies?*

    If yes, please list agency and type of services below.

  13. Participate in Congregate Meals?*

  14. Meals

    Meals are available Monday through Friday starting at 11:45 am. Please sign up for meals two days in advance.

  15. Need transportation to the Center?

    If yes, please check days transportation needed.

  16. Days transportation needed

  17. Medical Information

    In case of an accident, illness or other medical emergency which may occur while you are participating in an activity at the Oconee County Senior Center, this information will be provided to the medical care team so that they will have the necessary information for treatment. This information is confidential and will only be shared in cases of emergency.

  18. Hospital Preference*

  19. Insurance

  20. Medical Conditions and Prescription Information

  21. Are you diabetic?*

  22. Allergies?*

  23. Please list any medical conditions or type "none."

  24. Please list any medications you take or type "none."

  25. Consent for Medical Treatment

    I, the undersigned, give the Oconee County Senior Center staff permission to seek medical attention for me, if needed, and to give a copy of this form to the medical care provider.

  26. Hold Harmless Agreement

    I hereby release, absolve, and hold harmless the Oconee County Senior Center and the Oconee County Board of Commissioners, as well as representatives, employees, successors and assigns, for any and all claims for personal injury, property damage, death or other damages sustained while participating in county programs or while travelling in a county vehicle. I further release those parties named above from any liability, claim suit, or other action related to the preservation, release, or failure to release the medical information contained herein.

  27. Download and Print

    Please download and print the following additional forms; fill them out; then turn them in to Angela Helwig on your next visit to the Oconee County Senior Center.

  28. Thank you

    Thank you for registering to be a member of the Oconee County Senior Center. We are so glad to have you! We look forward to seeing you often at the center. Please let us know if you have any questions or need any kind of assistance. See you soon!

  29. Leave This Blank:

  30. This field is not part of the form submission.