Health Services Current Primary Care Clients Book an Appointment Chiropody Diabetes How to Become a Client Smoking Cessation System Navigation Telemedicine (virtual care) Urgent Care & Same Day Appointments Primary Care (Community Services) Counselling Chronic Disease Prevention Dietitian Services Lung Health Memory Care Clinic Primary Care – Outreach to Seniors Renfrew County Paramedic Program Education Resources Health Promotion and Group Programs Healthy Bodies Healthy Minds Healthy Eating Healthy Communities Renfrew County Good Food Box
Registration form for any Healthy Bodies related community programs If you need any assistance with registering, please contact Kara at 613-259-2182 ext. 2302. If you are using a cell phone or tablet(I-Pad) it’s best to turn it sideways to make entering information easier.ConsentBy completing this registration, I agree to the sharing of this information with ConnectWell Community Health and the community volunteers involved in the activity/activities I am registering for.(Required) Yes Have you registered for any of ConnectWell Community Health – Lanark Site's Community Progams before?(Required) Yes No Unsure Contact InformationLegal Name(Required) First Last Preferred Name (if different from above)Date of Birth(Required) DD slash MM slash YYYY Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Telephone Number (Please provide only numbers where you permit us to call)Preferred(Required)Message Allowed(Required)YesNoAlternateMessage AllowedYesNoEmail address – Please provide an email address that you permit us to use to contact you.Email(Required) Can we add your email address to our email distribution list to receive information about other Health Promotion Activities(Required) Yes No Emergency ContactName(Required) First Last Relationship(Required)Phone Number(Required)I would like to register for the following:Fit for Life – ActiveSelect between 1 and 3 choices. Ferguson Falls Hall, Tuesdays, 9:00-10:00 am (9 items remaining) Ferguson Falls Hall, Wednesdays, 9:00-10:00 am (11 items remaining) Middleville Community Hall, Tuesdays, 9:30-10:30 am (0 items remaining) Middleville Community Hall, Thursdays, 9:30-10:30 am (0 items remaining) Snow Road Community Centre, Wednesdays, 9:30-10:30 am (11 items remaining) St. Andrew’s United Church Hall-Lanark, Mondays, 9:00-10:00 am (0 items remaining) St. Andrew’s United Church Hall-Lanark, Wednesdays, 9:30-10:30 am (0 items remaining) St. Andrew’s United Church Hall-Lanark, Fridays, 9:00-10:00 am (0 items remaining) Tatlock Community Hall, Tuesdays, 9:00-10:00 am (8 items remaining) Zion Memorial Church Hall-Carleton Place, Tuesdays, 1:15-2:15 pm; (5 items remaining) Zion Memorial Church-Carleton Place, Thursdays, 1:15-2:15 pm (6 items remaining) Fit for Life – Gentle Balance ConnectWell Community Health, Mondays, 9:30-10:30 am (1 item remaining) ConnectWell Community Health, Mondays, 10:45-11:45 am (2 items remaining) ConnectWell Community Health, Wednesdays, 9:30-10 :30 am (4 items remaining) ConnectWell Community Health, Wednesdays, 10:45-11:45 am (6 items remaining) Ferguson Falls Hall, Tuesdays, 10:30-11:30 am (9 items remaining) Zion Memorial Church Hall-Carleton Place, Tuesdays, 2:30-3:30 pm (14 items remaining) Zion Memorial Church Hall-Carleton Place Thursdays, 2:30-3:30 pm (19 items remaining) Other Physical Activities Mindful Movement (currently not scheduled) (0 items remaining) Walkie Talkie Crew, ConnectWell Community Health, Tuesdays, 9:30-10:30 am (18 items remaining) PrivacyAs a participant I will respect the privacy and confidentiality of other individuals in the activity/activities selected.(Required) Yes Submission Block(Required)
