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I request and consent to the release by Onondaga County Department of Adult & Long Term Care Services of all requested records, including but not limited to, personal information, health information, and any other information concerning me that I have provided to Onondaga County Department of Adult & Long Term Care Services to the following entities so they can make referrals for services that I may need, or for the purposes identified as follows.
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In the event of a disaster or emergency, I consent to the release of information about services I receive, my housing situation and who I live with, medical equipment or services needed daily, prescription medications taken daily, special dietary needs, special communication needs, blindness or other visual impairments, and information about my general condition and mobility. 
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I release and discharge State University of New York Upstate Medical University (also known as SUNY Health Science Center at Syracuse), a component of which is University Hospital, State University of New York, and the State of New York, and their respective officers, trustees, directors, employees, and agents for any and all claims, demands, actions, losses, expenses, damages, and liabilities whatsoever in any manner related to or arising out of my participation in programs sponsored by Oasis including, but not limited to, educational, cultural, volunteer, physical fitness related programs, and travel in any form. 

I attest that I have full and informed knowledge of the risks involved in physical fitness activities and have full and informed knowledge of the risks involved in the programs sponsored by Oasis, and I attest that I have obtained approval from my physician(s) to participate in same. 

I understand that the Oasis mailing list may be used by Oasis sponsors for educational mailings. I understand that participants in programs sponsored by Oasis are expected to conduct themselves in a courteous manner, respecting the rights of all other participants, volunteers, and staff. I attest that I will conduct myself in a courteous manner and will respect the rights of all other participants, volunteers, and staff. I understand that if, in the sole discretion of State University of New York Upstate Medical University, I fail to conduct myself in a courteous manner and fail to respect the rights of all other participants, volunteers, and staff, I will not be allowed continued participation in the programs sponsored by Oasis. 

I give permission for The Oasis Institute to photograph or videotape me and to use my name and image in Oasis materials and publicity. I authorize the use of my name and image in publications produced by The Oasis lnstitute’s partners and by the media. I agree to be photographed or videotaped by the media for general publication.

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Tai Chi for Arthritis and Falls Prevention 16 Sessions - John Carno Recreation Center 823 State Fair Blvd Syr NY 13209

13:30:00-14:30:00 Monday, February 17, 2025