Thrive in Wellness Registration

Page 2

First Name

Last Name

Phone

Waivers and Covid-19 Information

By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of these Agreements. You further agree that your electronic signature on this document is as valid as if you signed the document in writing.

Media Release

I consent to and allow Mountain Resource Center to use and reproduce any and all photographs or videotapes taken of me during my participation in Family Education Programs. I understand that Mountain Resource Center will own the photographs and video and the right to use or reproduce such photographs and videos in any media, and the right to edit them or prepare derivative works for purposes of promotion, advertising and public relations. I hereby consent to Mountain Resource Center’s use of my name, likeness or voice, and I agree that such use will not result in any liability to these parties for payment to any person or organization including myself.

I ACCEPT

Liability Waiver

I understand the risks, hazards, and dangers inherent in carrying out normal day-to-day activities while participating in Family Education Programs. I agree for myself and my heirs, to release and hold harmless, defend and indemnify the Mountain Resource Center, its trustees, officers, agents, employees, and volunteers, from and against all claims, demands, actions, and causes of action as a result of personal injury, death, or property damage sustained by me or by others due to this activity.

I ACCEPT

Covid-19 Waiver and Guidelines

I understand and assume the risk that, despite MRC’s best efforts to prevent spread of the illness, I may become ill from COVID-19 and such illness may result in serious illness, up to and including death. I hereby assume the risk of bodily injury, illness, death, medical treatment, and property damage resulting from attending activities at Mountain Resource Center.

I will follow general CDC and the State of CO health guidelines by:

-Not attending class if I am currently experiencing symptoms of COVID-19 including but limited to coughing, congestion, loss of taste and smell, or fever.

- Not attending class if I have tested positive for COVID-19. If positive for COVID-19, I understand that I cannot come to class until 5 days have passed and I am symptom free. I also understand that I may return to class after the 5-day mark if symptom free, but I will need to wear a mask during the class until day 10.

These requirements may change at any time to comply with local and national guidelines.

I ACCEPT

Signature

Male	Female
Non-Binary	Prefer Not To Say

American Indian or Alaska Native	Asian
Black or African American	Hawaiian Native or Pacific Islander
Multiracial	White
Other	Prefer Not To Say

Phone	Email
Do Not Contact	No Preference

Living in car	Living in RV/Tent
Living with Friends/Family	Living in a Shelter
Living in a Rented Home	Living in a Owned Home

None	SNAP	Medicaid	TANF
Social Security	SSDI	Other	WIC
OAP- Old Age Pension	Prefer not to Answer

Spouse	Partner	Child	Grandparent	Grandchild
Family	Friend	Other	Self	Guardian
Ward	Foster Parent	Foster Child

	Often True	Sometimes True	Never True	Prefer Not To Answer
Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more
Within the past 12 months we worried whether our food would run out before we got money to buy more

	Yes	No	Not Applicable
Is your housing unstable? Do you have trouble paying rent?
Are any adults in your household unemployed/ underemployed?
Are there members of your household that do not have access to a medical provider?
Are there members of your household without health insurance?
Do you want parenting support and resources?
Would you like to receive the newsletter?