Register here for AFA Barbara Rabinowitz Education & Resource Center Community Classes

All programming takes place at 149 Schleigel Boulevard, Amityville, New York. Please call the Center 631-223-4000 if you need assistance registering or have any questions.

*Registering more than one person?
Each attendee must be registered individually.

"*" indicates required fields

Upcoming Classes

Name*

First Name Last Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Are you living with or affected by Alzheimer’s disease, other dementias, or memory loss*

Yes

Are you a:*

Caregiver

Healthcare Professional

Community Member

Will you be accompanying/be accompanied by someone?*

Please note you will need to register your guest/companion separately.

Guest/Companion Name

First Name Last Name

How did you hear about the AFA Barbara Rabinowitz Education & Resource Center?*

If other, please specify:

Therapeutic Program Agreement*

I have read and agree to the Terms of Service Agreement listed below

I agree to participate in a Therapeutic Recreation group hosted by the Alzheimer’s Foundation of America, Inc. (“Alzheimer’s Foundation of America”) and facilitated by a Recreation Therapist or other professional and/or licensed therapist employed or engaged by the Alzheimer’s Foundation of America.

I understand that the purpose of this Therapeutic Recreation group is to provide a forum for participants to connect with one another, and promote physical, emotional, social, and cognitive engagement with the hope of improving overall health and well-being.

I agree, that if I engage in any physical exercise or activity upon entering Alzheimer’s Foundation of America’s premises or use any facility or equipment on the premises for any purpose, I do so at my own risk and assume the risk of any and all injury and/or damage that may occur, whether while engaging in physical exercise or not. This includes injury or damage sustained while and/or resulting from exercise, activity or using any equipment. If I have any doubt as to my ability to successfully and safely participate in any exercise or activity, I take full responsibility for consulting a physician.

I understand, that the Alzheimer’s Foundation of America cannot prevent me or my family from becoming exposed to, contracting, or spreading COVID-19, while participating in therapeutic programs on the Alzheimer’s Foundation of America’s premises. By attending therapeutic programs at the Alzheimer’s Foundation of America, I understand the risk of exposing myself to and/or the increased risk of contracting or spreading COVID-19.

I understand that the Therapeutic Recreation group is confidential, except as mandated by law. In certain situations, Alzheimer’s Foundation of America is required by law to reveal information obtained during group sessions to other persons or agencies without my consent. These situations include, without limitation, cases of suspected abuse/neglect of children or the elderly; and cases of potential harm to self or others.

I understand that this group does not take the place of consultation with a physician or other healthcare professional on any issues related to my health and/or formal mental health or substance abuse treatment, and agree to seek assessment and treatment for mental health/substance abuse or other issues by an appropriate clinician should the need arise. Should I have thoughts of harming myself or others, I agree to obtain immediate assistance from a medical professional.

It is the Alzheimer’s Foundation of America’s policy to protect the privacy and confidentiality of group members; only first names will be used during sessions. The Alzheimer’s Foundation of America does not share group members’ personal information (i.e., last name, email address, Facebook page, phone number or mailing address), unless required by law as described above.

I hereby forever release, waive and discharge any and all liability, claims and demands of whatever kind or nature against the Alzheimer’s Foundation of America, and its representatives and agents, including without limitation its owners, officers, directors, managers, trustees, agents employees, volunteers or other representatives, either in law or equity to the fullest extent permissible by law, arising from or relating to my role as a member of the Therapeutic Recreation group (including, but not limited to, a situation in which I choose to share my personal information with other group members) and/or any exercise or activity I engage in as a member of such group.

I understand that this agreement means I give up my right to bring any claims including for personal injuries, death, disease, property loss or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen, or unforeseen.

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Photo Consent Form*

I agree to the photo release form below.

I choose not to appear in photos.

I hereby grant to the Alzheimer’s Foundation of America, Inc. (the “Foundation”) the absolute and irrevocable right and unrestricted permission to use and/or reproduce my (and/or my child’s or children’s) name, likeness, image, voice, and/or appearance as such may be embodied in any photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of the Foundation. I agree that the Foundation has complete ownership of such material and can use said material for any purpose consistent with the Foundation’s mission. These uses include, but are not limited to, videos, publications, advertisements, news releases, Web sites, and any promotional or educational materials in any medium. I acknowledge that I will not receive any compensation for the use of such images, video, likeness, etc. I hereby release and discharge the Foundation, and its agents, representatives and assignees from any and all claims and demands arising out of or in connection with the use of my name, likeness, image, voice and/or appearance, including any and all claims for invasion of privacy, right of publicity, misappropriation or misuse of image, and/or defamation. I represent that I am over the age of eighteen (18) years (or I am the parent or legal guardian of one or more children to whom this release applies) and that I have read the foregoing and fully understand its contents. This release shall be binding upon me, my heirs, legal representatives, and assigns. This release is being made and entered into under the laws of the State of New York and shall be governed and interpreted in accordance with the laws of said state. This agreement embodies the entire agreement of the parties.

Photo Consent Form*

I agree to the photo release form below.

I choose not to appear in photos.

Notes:

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