Name *

First Name

Last Name

Phone Number

(###)

###

####

In order to qualify for the FREE Willis Clinic you must answer yes to the 4 questions below.

I agree

Are you a Dallas County resident?

Yes

No

Are you age 50 or oler?

Yes

No

Are you a US citizen or legal resident?

Yes

No

Do you have limited income?

Yes

No

COVID-19 WAIVER (Applicable for in-person meetings at Frazier House) *

I acknowledge that I must comply with all set procedures by Zan W Holmes Jr. Community Outreach Center to reduce the spread of all Covid variants while on the premises. I attest that I hereby release and agree to hold Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the center, or that may otherwise arise in any way in connection with any services received from Zan Wesley Holmes Jr Community Outreach Center or any other collaborating partner. I understand that this release discharges Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner have against our organizations with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services from Zan Wesley Holmes Jr Community Outreach Center, or any other collaborating partner This liability waiver and release extends to the center together with all owners, partners, and employees.

I agree

PHOTO CONSENT *

Submission of this form gives Zan Wesley Holmes, Jr. Community Outreach Center permission to capture and display photos of the event and its participants for professional promotional purposes. We own all rights to photos taken.

I agree