Carebridge Community Support

Senior’s Wellness Program Registration Form

First Name: *

Last Name: *

Address:

Home phone:

Cell phone:

Email: *

Emergency Contact Name:

Emergency Contact Phone Number:

Date of Birth:

Health Card #:

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Program(s) you wish to register for:

Please specify the program

Do you have any medical or general health concerns that staff should be aware of?

If yes, please explain

How did you hear about these programs?

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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.

Has your doctor ever said that you have a heart condition OR high blood pressure? *

Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? *

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? *

Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *

Please list condition(s) here: *

Are you currently taking prescribed medications for a chronic medical condition? *

Please list condition(s) and medications here: *

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *

Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

Please list condition(s) and medications here: *

Has your doctor ever said that you should only do medically supervised physical activity? *

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

I, the undersigned, waive all rights for myself, my heirs, successors, executors, administrators and assigns, and release Carebridge Community Support, its employees, agents and contractors, from all claims, without limitation for any and all personal injuries and illness suffered by me as a result of my participation in the Carebridge Community Support exercise programs. I am aware that the activity can result in personal injury and/or illness which can activate or aggravate pre-existing physical injuries, conditions, symptoms, or congenital defects. I have no reason to believe that my physical condition may be incompatible with such activities. While Carebridge and the instructors of their exercise programs take every precaution, the use of exercise equipment can result in personal injury which can activate or aggravate pre-existing physical injuries, conditions, symptoms, or congenital defects. I have no reason to believe that my physical condition may be incompatible with the use of such equipment. I freely accept and fully assume all risks, dangers and hazards associated with this activity and the possibility of personal injury, illness, death, property damage or loss resulting therefrom.

Date *

Signature *

Type your full name here

Carebridge Community Support connects and is a catalyst for fostering stronger, caring, person-centred communities across Lanark County by working together to meet the needs of seniors, adults with developmental disabilities and those who need affordable housing.

Senior’s Wellness Program Registration Form

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