New Customer Registration Form

Patient Engagement Event Registration Form
Event Name:
Community Day to End Violence BBQ

Date: Monday, September 1st, 2025

Time: 12:00 PM to 5:00 PM

Location:

Pavilion 2 at Ridge Road Park

287 Ridge Road

Hartsdale, NY 10530
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Refreshments may be served at this event. Please read the waiver below and initial where indicated.

Waiver of Liability
I understand that I am voluntarily participating in an event provided by Family Services of Westchester on this day. I acknowledge that the food provided may contain allergens and carry risks of allergic reactions, illnesses, or choking. I release Family Services of Westchester and its employees, volunteers, and affiliates from any liability for any allergic reactions, illnesses, or injuries that may occur as a result of my participation of this event. I understand that it is my responsibility to inform the organizers of any food allergies or dietary restrictions I may have.
Initial here:
Permission for Photography
Family Services of Westchester staff will be taking photos at this event for the purposes of creating a social media post.
Should be Empty:

Patient Engagement Event Registration Form