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Renfrew County – Fit, Fun & Fully Alive! Group Fitness Classes for Older Adults Group Registration Form
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Renfrew County - Fit, Fun & Fully Alive! Group Fitness Classes for Older Adults Group Registration Form
Which Class type are you registering for?
(Required)
Please Select
Active - COBDEN
Active - WESTMEATH
Gentle - COBDEN
Men's Class - COBDEN
Name
(Required)
First
Family(Last)
Preferred Name (if different from above)
Date of Birth
(Required)
MM slash DD slash YYYY
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)
Please Select
Yes
No
Alternate Phone
Message Allowed
Please Select
Yes
No
Mobile/Cell Phone
Message Allowed
Please Select
Yes
No
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)
No
Yes
I give Health Centre staff permission to send me information by mail.
(Required)
Please Select
Yes
No
Emergency Contact
Name
(Required)
First
Last
Relationship
(Required)
Phone
(Required)
Is this the first time you have participated in one of our programs?
(Required)
Please Select
Yes
No
Privacy Agreement
(Required)
As a participant of this group, I will respect the privacy and confidentiality of other individuals in the group
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