Fit, Fun & Fully Alive! Group Fitness Classes for Older Adults Group Registration Form
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Indicates a required field
Please complete this registration form and more details will be emailed to you regarding participation in our online classes.
You can call ConnectWell Community Health - Renfrew County Sites for more information – 613-582-3685.
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Which Class type are you registering for? :
Select
Active - COBDEN
Active - WESTMEATH
Gentle - COBDEN
Men's Class - COBDEN
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Family (Last) Name:
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First Name:
Preferred Name (if different from above):
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Date of Birth (Day / Month / Year):
e.g. 12/03/1955
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Street/Road/RR :
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Town/City :
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Province:
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Postal Code:
Telephone Number (Please provide only numbers where you permit us to call
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Preferred:
Alternate:
Mobile/Cell:
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Message Allowed:
Select
Yes
No
Message Allowed:
Select
Yes
No
Message Allowed:
Select
Yes
No
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Email address:
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).
Please provide only email that you permit us to use to contact you.
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I give Health Centre staff permission to send me information by mail :
Select
Yes
No
Emergency Contact
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First and Last Name:
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Relationship:
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Phone Number:
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Is this the first time you have participated in one of our programs?:
Select
Yes
No
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As a participant of this group, I will respect the privacy and confidentiality of other individuals in the group.
