Watercolor Workshops "*" indicates required fields Step 1 of 4 25% Enter requested information below. * Required First Last Email * Required Phone * RequiredResidence County * RequiredBentonWashingtonMadisonBaxterBooneCarrollIzardMarionNewtonSearcyStoneOtherGender * RequiredMaleFemaleOtherRace * RequiredAfrican-AmericanAmerican IndianAsian / Pacific IslanderCaucasianHispanicMiddle EasternOtherProfession * RequiredPublic/CommunityDieticianMedical StudentNursingNursing Home AdministrationParaprofessionalPatientPhysical TherapyPhysicianResidentSocial WorkStudentHow did you learn about this program?My Center on Aging (the Schmieding Center)FacebookWebsiteWord of MouthMy Healthcare Provider (e.g., doctor, nurse, etc.) Register for Zoom or In-Person Workshop? * RequiredIn-PersonZoomUAMS Event Safety Policy * RequiredI have carefully read the UAMS Event Safety Policy and agree to release and waiver of all potential claims and causes of action while participating in this event at the UAMS Schmieding Center. I agree to indemnify UAMS of any liability for injury or death from my participation in this event caused by my negligent or intentional act(s) or omission(s). I agree Select the time for the IN-PERSON classes you want to attend * Required(This registration is for the next 3 class offerings)10a-Noon classes on Oct 24, Nov 21, and Dec 121p-3p classes on Oct 24, Nov 21, and Dec 12Select the time for the ZOOM classes you want to attend * RequiredThis registration is for the next 3 class offerings)10a-Noon classes on Oct 24, Nov 21, and Dec 121p-3p classes on Oct 24, Nov 21, and Dec 12 CONSENT TO USE MEDIA IMAGES FOR PROMOTIONS I hereby give the University of Arkansas for Medical Sciences, their legal representative, assigns, and those acting on their behalf and with their permission, the right and permission to copyright in any part of the world, to use, reuse, publish and republish, in conjunction with my own or fictitious name, any photograph, film or video tape recording taken of me by the University of Arkansas for Medical Sciences or those acting on their behalf or with their permission, and any reproductions thereof, in any form, whether intentional or otherwise, and may be used in conjunction with any advertising material, for any purposes of trade, advertising, exhibit, publicity, or promotion, without restriction or limitations. I understand that the photographs, film and/or video may be used in news releases, newspapers or magazine articles, television, the UAMS website or social media sites (e.g., Facebook , YouTube). I hereby release, discharge, and agree to save harmless the University of Arkansas for Medical Sciences, their assigns, legal representatives, agents, and those acting on their behalf and with their permission, from and against any liability resulting from any distortion, blurring, alteration or use in composite form, whether such was intentional or otherwise, which my occur, result, or be produced in the taking of said photography, or by processing or reproduction of the finished product, its publication or the distribution of same. I waive the right to approve or inspect the recordings, advertising copy, or material used in conjunction therewith.I consent, per above terms, to the use of my image by UAMS for program and event promotion * Required Yes No I want to receive email notice about other Schmieding Center events * Required Yes No Survey data is required by our funder to offer this program at no cost to participants. Only aggregate (group) data from this survey is reported. How often do you feel that you lack companionship? * Required Hardly ever Some of the time Often SCSHE How often do you feel left out? * Required Hardly ever Some of the time Often SCSHE How often do you feel isolated from others? * Required Hardly ever Some of the time Often SCSHE TestimonialYour comments about this program. For example. why did you register, what has helped, etc.
