http://cm2wflc.neworg.com/compformdisplay.asp?pagenum=94&formnum=21&cn=&can=&sid=1010312266
Client Registration
 

If any questions, please call in at 203-458-6699.
 
                                                    Welcome to our registration form 
 
                                              Please fill in the fields of information below.
  
                                         If it is not safe to receive e-mails, please call us to register: 203-458-6699

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Review our Confidentiality and General Liability Agreement below. Once read indicate your agreement by selecting "I agree" and date below.

Women & Family Life Center (WFLC) Waivers and Agreements

Confidentiality Statement:
I understand that all information shared and discussed with Women & Family Life Center staff is confidential. Information will not be disclosed to outside persons unless there is suspicion of or evidence of child abuse, elder abuse (age 60 and over), abuse of persons with disabilities and/or the participant is a risk to oneself or others. The Center's staff are mandated reporters and have a legal and ethical obligation to report the above information to the proper authorities.

Scope of Services and Program Liability Statement:
I understand that when working with any program facilitator, said professional is representing Women & Family Life Center and not a private business. Some examples include the social workers, financial advisors or attorneys who facilitate programs. These individuals are not selling any particular goods or services. They will give general information for educational purposes and are not treating me therapeutically, representing me legally or managing my affairs financially. The Center's staff and facilitators may provide with me referral information on a variety of public and private resources. Providing this information does not construe an endorsement of individual providers or indicate eligibility for services. It is my responsibility to ascertain the appropriateness of utilizing any of the recommended resources. I agree to hold WFLC and its facilitators harmless from liability for any claims related to the issues discussed during programs. I also understand that WFLC is not responsible for any outcomes or lack thereof from referrals.

General Liability Statement:
I understand that all participation in physical activity is by my own choice and at my own risk. WFLC and its facilitators are in no way liable to me for any claims, demands, injuries, damages or actions arising due to injury of my person or property at the premises. I agree to hold WFLC and its facilitators harmless from any and all claims which may be brought against WFLC and its facilitators for any such injuries or claims.

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Household size (number of people counted in your taxes) Gross income (before taxes) for all household members combined
1 $18,210
2 $24,690
3 $31,170
4 $37,650
5 $44,130
6 $50,610
7 $57,090
8 $63,570