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Petersburg Parks & Leisure Services - Senior Program Registration Form

  1. First Name of the participating Senior Citizen

  2. Last Name of the participating Senior Citizen

  3. APT. #

  4. Age Birthdate (Month, Date, Year)

  5. Month/Year

  6. Please list date of last physical for the above person. If the applicant is on medication please state the type of medication and the condition being treated. Your physician must send a letter stating that you can participate in an independent recreation program that includes, aerobics, line dancing and walking prior to you participating in the program.

  7. Please list name of the closet relative address, cell number or best number and email address.

  8. Please list the name, address, cell number or best number and email address of your emergency contact person.

  9. I agree that my participation in this program or activity and or any changes will be in pursuant of the rules established by Petersburg Parks & Leisure Services. I further indemnify and hold the City of Petersburg and its employees hold harmless from any liability, for any injury that may be suffered due to participation in this activity or program. I give permission for your photographers to take photos for marketing purposes only,

  10. Signature

  11. Month/Date/Year

    Select Yes or No

  12. Leave This Blank:

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


City of Petersburg - Virginia