Workshop Consent Forms NCOA Consent Form Statement of ConsentPlease show us that you understand the information on the Participant Consent Form and how your survey information will be used. Check each box you agree to and sign below. Typing your name and today’s date will act as your digital signature.Workshop Start Date(Required)Workshop Type (Please Select from List)(Required)Aging Well with PainAging Well with Health ConditionsAging Well with DiabetesPowerful Tools for CaregiversA Matter of BalanceTai Chi for Arthritis and Falls PreventionBingocizeAging MasteryI have read the information on this form or it has been read to me. I understand the information and have received answers to any questions I asked. I understand that I do not have to complete the survey and if I do not, it will not affect the services I receive. I agreeI agree to allow my survey information to be shared with ACL and its contractors. I agreeI agree to allow my gender, zip code and date of birth to be shared with CMS or its contractors to match with my Medicare claims information. I agreeSignature of Participant(Required) First Name Last Name Date(Required) MM slash DD slash YYYY Signature of Guardian/Family Member/Legal Representative First Name Last Name Date MM slash DD slash YYYY Relationship to ParticipantPlease provide the email address you used to register for the workshop(Required) Signature(Required)UntitledNumberNumber
