EmailMeForm
Stepping On
Mondays, 1-3 p.m.
March 26th - May 7th
$35/7 Sessions
Wil-Mar Neighborhood Center
953 Jenifer St.
Name
*
First
Last
Home Phone
###
-
###
-
####
Email
*
Mobile Phone
###
-
###
-
####
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Do you live in a house or apartment? Note: If your answer is NO, this workshop may not be appropriate for you. Consider talking with your doctor about having a falls assessment and other methods of preventing falls.
*
Please select
YES
NO
Are you able to walk without the help of another person? Note: If your answer is NO, this workshop may not be appropriate for you. Consider talking with your doctor about having a falls assessment and other methods of preventing falls.
*
Please select
Yes
No
Do you use a walker, scooter or wheelchair most of the time indoors? Note: If you need assistance with a walker, scooter or wheelchair most of the time when walking indoors, this workshop may not be appropriate for you. Consider talking with you doctor about having a falls assessment and other methods of preventing falls.
*
Please select
Yes
No
Have you fallen in the past year? Note: If you have fallen six or more times in the past year, consider talking with your doctor about whether you may benefit from additional individualized assesment or intervention.
*
Please select
Yes
No
Do you have problems with your vision? If yes, please describe below what we'd need to do to accommodate your needs in the workshop.
*
Please select
Yes
No
If you answered "yes", please describe what we need to do to accommodate your needs:
Do you have any problems with your hearing? If yes, please describe below what we'd need to do to accommodate your needs in the workshop.
*
Please select
Yes
No
If you answered "yes", please describe what we need to do to accommodate your needs:
Class fee is $35. Please indicate below if you are interested in hearing more about available tuition assistance.
How did you hear about the Stepping On workshop?
*
Healthcare provider
Friend/Word of Mouth
Listserve Email
Wil-Mar Email
Safer Community Website/Email
Brochure (Please list where below)
If you answered "Brochure" above, please list the location you picked it up.
Comments or Questions?
Informed Consent and Hold Harmless/Release Agreement:
I understand that participation in exercise activities involves a certain degree of risk. I have carefully considered the risk involved and I understand that participation in these activities is entirely voluntary. By clicking the box below, I release the Wil-‐Mar Neighborhood Center and the instructor from any and all claims of liability arising out of my participation in this class. Photos may be taken during a session and I allow these to be used for educational and marketing purposes.
*
I have read and agree to the above statement.
Powered by
EMF
Survey
Report Abuse