Lanark Site – Fit for Life Exercise-Gentle Balance to Prevent Falls

If you need any assistance with registering, please contact Pam at 613-259-2182, ext. 2306 or Kara at 613-259-2182 ext. 2302

I would like to register for the following:(Required)

( choose only one please)

ConnectWell Community Health - Lanark, Wednesdays and Fridays 9:00 - 10:00 am (1 item remaining)

ConnectWell Community Health - Lanark, Wednesdays and Fridays, 10:15 - 11:15 am (2 items remaining)

Zion Memorial Church - Carleton Place, Wednesdays and Fridays, 2:15 - 3:15 pm (15 items remaining)

Snow Road Hall, Wednesdays, 11:00 - noon (12 items remaining)

Name(Required)

First Last

Preferred Name (if different from above)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Preferred(Required)

Message Allowed(Required)

Alternate

Message Allowed

Email(Required)

Please provide an email address that you permit us to use to contact you.

Name(Required)

First Last

Relationship(Required)

Phone Number(Required)

As a participant of this group, I will respect the privacy and confidentiality of other individuals in the group.(Required)

Yes