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Senior’s Wellness Program Registration Form



The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

Please read the 7 questions below carefully and answer each one honestly: select YES or NO.

Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).
Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.


Release of Liability, Waiver of Claims, Assumption of Risks Agreement

Type your full name here