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2. 

4. The SRC is for participants age 55 & older. Some grant funded programs have different age & eligibility requirements.

6. First Name*
7. Last Name*
9. Address Line 1*
11. Address Line 2
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Cell Phone (if different)
20. Email Address
22. Would you like to subscribe to the SRC Newsletter via Email?

    1. Yes
    2. No
24. Many classes and activities require pre-registration. We offer an on-line client portal which allows participants to pre-register for upcoming classes from their own computer. Would you like to enroll?

    1. Yes
    2. No

    If no, you may also pre-register for classes at the kiosk in the lobby at the Senior Resource Center, or by phone at 798-6450.

26. Date of Birth*
    Date of Birth
27. Primary Language

    1. English
    2. Spanish
    3. Other
28. If other language please specify:
30. Gender

    1. Female
    2. Male
    3. Transgender
    4. Other
31. If other please specify:
33. Emergency Contact Name
34. Emergency Contact Phone Number
36. Emegency Contact Relationship

    1. Spouse
    2. Partner

    1. Child
    2. Friend

    1. Neighbor
    2. Caregiver

    1. Other
40. Race

    Select the one race with which you most identify

    1. Black or African-American
    2. Asian
    3. American Indian/Alaska Native
    4. White
    5. Hawaiian/Pacific Islander
41. Ethnicity

    1. Not Hispanic or Latino
    2. Hispanic Puerto Rican
    3. Hispanic Mexican American
    4. Hispanic Cuban
42. Household Size

    1. Lives alone
    2. 2 in home
    3. 3 or more in home
    4. Group/Shared home
    5. Homeless
43. Veteran

    1. Yes
    2. No
    3. Spouse of Veteran
45. How did you hear about the Senior Resource Center?

    1. Friend/Family
    2. Doctor
    3. Newsletter
    4. Social Media
    5. Get to Know SRC Presentation
    6. Community Event
    7. Other
46. If other, please specify:
48. Are you interested in volunteer opportunities?

    1. Yes
    2. No
52. What medications are you currently taking?
53. Are you allergic to any medications?

    1. Yes
    2. No
54. If Yes, please specify:
56. Please list additional Medical Information we need to know in case of an emergency, accident, injury, sudden illness, etc.
58. Physician's Name
59. Specialty
61. Physician's Address
63. Physician's Phone Number
67. Electronic Agreement

    Photo Release

    Notice:  By being on this property and/or entering this facility, you hereby agree that photos of you taken in this facility or on the property may be used for advertisement, promotion, documentation, or for any other purpose deemed necessary by the New Hanover County Senior Resource Center.  Photos may be posted on a bulletin board, included in a newsletter, brochure, flier, included in various media, etc.

    Title III-D Evidence Based Health Promotion (EBHP)

    Title III-D Evidence Based Health Promotion (EBHP) classes such as Geri-Fit, Tai Chi for Arthritis (TCA), Walk with Ease (WWE), Eat Smart Move More Weigh Less (ESMMWL), and A Matter of Balance (AMOB) are offered to seniors 60 years of age and older on the date of enrollment at no charge.  However, contributions to support these classes are encouraged and always welcome.   Thank you.

    Waiver and Release of Liability

    I, the undersigned participant, do hereby release, absolve, indemnify, and hold harmless

    New Hanover County, staff, agents, employees, instructors, both paid and volunteer: from injury, claim, demand, cause of action, or other liability, including attorney fees, which may occur from my participation in an activity/class and/or use of exercise equipment at/sponsored by New Hanover County.  I have completed the above health information to the best of my knowledge and have consulted my physician regarding participation in classes which require physical activity.

    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.

    1. I agree.
69. Electronic Signature

71. Please allow up to 10 business days to be entered into our participant system. If you enrolled in the online portal you will receive an email with a temporary password to log in to the "SERVTracker Client Portal". You will also receive an ID badge in the mail. Please be sure to swipe in with your badge each time you arrive, and select ALL activities you will be participating in that day. If you have any questions or to check on your registration status please contact (910) 798-6450 or email Shantel Davis 

    Thank you for your interest in the SRC. We are happy to serve you!

    Below are some helpful links to get to know the NHC Senior Resource Center!

    Instructions on How to Use the Online Portal 
    View the latest newsletter
    Participant Guide 

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73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit Submit and Print

* indicates a required field