Vineyard Community Center - Columbus Ohio

6000 Cooper Rd | Westerville, OH 43081

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Co-ED Adult Indoor Soccer League - Mondays

Monday, August 26, 2019 to Thursday, December 12, 2019
Mondays, 6:00 PM to 9:00 PM

Activity/Service #

First Name *

M.I.

Last Name *

Address *

City *

State *

Zip *

Phone (home)*

Phone (cell)

Phone (work)

Email *

Church Attendance

Do you attend, or are you a member of Vineyard Church of Columbus?
Yes No

Age (if under 18) *

If under 18, check here to certify that you have the permission
of a parent or legal guardian.

How did you hear about the class or program you are signing up for (select all that apply): *

	Post card received in the mail
	Website
	The Program (received in the mail)
	The Program (picked up copy at Vineyard)
	Friend, word of mouth, or other means

Program Participation *

Have you ever participated in a Vineyard Community Center class or program before?
Yes No

In case of an emergency contact:

Name *

Phone *

Relationship

Additional Information:

Please select your team:

Coupon Code

Apply Coupon

Fee Total

Credit Card Type *

Credit Card # *

Name on Card *

Exp. Date *

AGREEMENT TO INDEMNIFY, AND NOT SUE, AND RELEASE OF ALL CLAIMS

I desire for myself and/or my child(ren) listed above (collectively, whether one or more, the “Participants”), voluntarily and with full assumption of all risks, to participate in the Vineyard Community Center program(s) described above and all incidental activities (collectively, the “Activity”), and in consideration of your acceptance of this registration, I agree, for myself, the Participants, and my/their respective representatives and successors-in-interest to waive and release Vineyard Community Center and Vineyard Church of Columbus and their respective officers, trustees, directors, employees and agents from all liability for any injury, damage, or loss incurred or suffered by any Participant resulting directly or indirectly from any Participant’s participation in any Activity, including without limitation the provision of any first aid, emergency or other medical attention necessitated by the Participant’s participation in any Activity. I hereby grant and give Vineyard Community Center and Vineyard Church of Columbus the right to use each Participant’s photograph or image with or without my/our names, both single and in conjunction with other persons or objects for any and all purposes, including but not limited to private or public presentations, advertising, publicity and promotion.

PLEASE READ CAREFULLY, BY SIGNING YOU WAIVE CERTAIN LEGAL RIGHTS.

By checking here, I certify that I have read and agree to the terms and conditions listed above.

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The Vineyard Childhood Center:	Monday through Friday, 7am - 6pm Year Round
Health Clinics:	Vineyard Free Health Clinics 6000 Cooper Road, Westerville, Ohio 43081 Vineyard Free Health Clinics provide free medical, chiropractic, dental and vision care for patients who qualify. Our clinics serve those ages 18 and up who are uninsured OR have Medicaid or are Medicaid eligible with incomes below 200% of the Federal Poverty Level. (No Medicare or other government-issued health care programs are eligible for services.) Medical Clinic Tuesday Evenings: Walk-in, first-come, first served. Registration begins at 4pm. Doctors begin seeing patients at 6:15pm. We provide diagnosis and treatment of illnesses only. Basic work physicals available by calling prior to coming to the clinic. No lab tests, injections, or X-rays. Call: 614.259.5428 (Option 6) Dental Clinic By appointment only. We provide dental exams, fillings, extractions and cleanings. No wisdom teeth, bridgework, orthodontics or dentures. Call: 614.259.5428 Fridays, 9:00am – 9:45am to schedule an appointment. Vision Clinic By appointment only. We offer eye exams and vouchers for free eyeglasses (by application) to qualified individuals. Call: 614.259.5428 Fridays, 10:00am – 10:30am to schedule an appointment. Chiropractic Clinic By appointment only. We provide evaluation and care for those with pain involving the head, neck, back or joints. No X-rays. Call: 614.259.5428 Fridays, 10:00am – 10:30am to schedule an appointment. Lower Lights Christian Health Center LLCHC is a faith-based, non-profit community health provider ministering the love of Christ through full service cradle-to-grave medical care focused on whole person wellness. They see patients with Medicaid, Medicare, CareSource, Molina and private insurance as well as uninsured patients. Services are offered for the whole family on a sliding fee scale based upon income; however, all patients are seen regardless of ability to pay. Please call to schedule an appointment. Vineyard Community Center hosts LLCHC at its two clinic locations: · 6000 Cooper Road, Westerville, Ohio 43081 Hours: Monday, Wednesday, Thursday, & Friday: 8:00am – 5:00pm Tuesday: 8:00am – 3:00pm · 171 E 5^th Avenue, Columbus, Ohio 43201 Hours: Monday – Friday: 8:00am – 5:00pm Services offered at both locations: § Routine Care § Physicals § Chronic Disease Management § Well-Child Checkups § Labs Contact Information: Lower Lights Christian Health Center Call: 614.274.1455 (Option 1)
Programs and Services:	Monday through Thursdays, 8am-9pm; Fridays 8am-6pm Saturday, 9am-2pm Sunday- At Specific Times
Church Service:	Times and locations

Monday-Friday:
Saturday:
Sunday:

Vineyard Community Center
6000 Cooper Rd.
Westerville, OH 43081
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