Membership Form First Name*
Last Name*
Middle Initial
Address*
City*
State*
Zip Code*
Phone Number*
Email Address*
Date of Birth*
Name of Spouse/Partner
Emergency Contacts Name Emergency Contact 1*
Phone Number Emergency Contact 1*
Relationship to Emergency Contact 1*
Name Emergency Contact 2
Phone Number Emergency Contact 2
Relationship to Emergency Contact 2
Participant Release and Waiver of Liability Your Full Name*
Member Code of Conduct The Bigelow Center for Senior Activities is dedicated to promoting a dignified, healthy quality of life for older adults by advocating for vital services, providing opportunities to develop meaningful fellowship, offering lifelong learning activities, recognizing the continued and varied accomplishments of older adults, and being an accessible and trusted community resource. Consistent with these goals, the Bigelow Center requires that all members and guests abide by the following rules of conduct and general facility rules. Failure to abide by these requirements may result in the individual violating the rule being asked to leave the Bigelow Center. Severe or pervasive offenses, as determined in the Bigelow Center’s sole discretion, may result in temporary or permanent exclusion from the Bigelow Center.
• Treat everyone with respect.
• The use of abusive, intimidating, lude, threatening, or harassing language, body language, or gestures is strictly prohibited.
• Fighting, physical abuse, challenging others to fight, destroying or damaging property and other disruptive, intimidating or harassing behaviors are strictly prohibited.
• Alcohol or illegal drugs shall not be brought to the Center or Center grounds. Anyone under the influence of alcohol or illegal drugs will be asked to leave the Center.
• Weapons of any kind are not permitted in Bigelow Center, or while in or on the premises where the program or activity is being conducted.
• The Center does not provide sleeping accommodations. Lying outstretched or sleeping on the furniture or the floor is not allowed.
• Proper shoes and appropriate clothing must be worn at all times. Participants are expected to maintain reasonable standards of personal hygiene and wear clean, suitable attire while attending Center programs, activities, and transportation services. Participants, their clothing, personal belongings, and any service animal accompanying them must not create health, safety, sanitation, or significant odor concerns that disrupt Center operations, transportation services, programs, activities, or the enjoyment of others. Staff will make reasonable efforts to address concerns respectfully and privately whenever possible. Participants may be asked to address the issue before participating or may be required to leave for the day if necessary to maintain health, safety, or the reasonable enjoyment of the facility by others.
• No solicitation or sales of goods or services by an individual, participant or group are allowed.
• Participants who cause an unreasonably loud noise that is disturbing or annoying may be asked to leave the building.
• Please refrain from any PDA (public display of affection) which includes but is not limited to: sexually implicit dancing, kissing, groping and lap sitting.
• All Town of Fairfield Facility Policies as set by the Fairfield Health Department and Town of Fairfield apply to the Bigelow Center. In times of health concerns, appropriate facemasks may be required and hands must be sanitized upon entry. Those who refuse will not be permitted to enter the building.
General Facility Rules • Participants must complete and submit a registration form annually and scan card/sign-in at each visit.
• Participants are not allowed in staff areas (kitchen, offices, closets) without staff permission.
• Service Animals (as defined by federal and state law) may enter the Center, must be restrained, and under the supervision of their companion or owner at all times.
• Animals may not be left unattended outside the Center.
• Community phone use is limited to local calls for emergencies.
• Restrooms shall not be used for bathing, shaving, or washing clothes.
• Smoking is strictly prohibited in the building or on the premises.
• Personal belongings must not be left unattended.
• Any minor visiting the Center must be signed in and supervised by his/her guardian at all times. Minors who are volunteering must have parental approval under the supervision of designated staff, teacher or parent at all times.
• All senior center participants under 60 years of age who participate in the lunch program shall pay $13.00 per meal and wait until eligible seniors have been served.
• Surveys, photographs, or video recording in the Center require prior written permission of the staff. Release forms are required.
Agreement of Participant Your Full Name*
