Renfrew County Fit, Fun & Fully Alive! Group Fitness Classes for Older Adults Group Registration Form

Which Class type are you registering for?(Required)

Name(Required)

First Family(Last)

Preferred Name (if different from above)

Date of Birth(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Telephone Numbers

(Please provide only numbers where you permit us to call)

Prefered Phone(Required)

Message Allowed(Required)

Alternate Phone

Message Allowed

Mobile/Cell Phone

Message Allowed

Email Address(Required)

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

This form has been completed by a third party for individual(s) without an e-mail address, please do not use the above e-mail address to contact them, use the provided Telephone number(s).(Required)

I give Health Centre staff permission to send me information by mail.(Required)

Emergency Contact

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Is this the first time you have participated in one of our programs?(Required)

Find Out What Services Are Available To You