Virtual Fitness Series

Virtual Fitness Series Registration

8-Class Series - Monday Jan 4 through Monday Feb 22
Participant Information
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
E-mail *
example@example.com
Date of Birth *

Month Day Year
What is your gender? *

Male Female I prefer not to answer
Are you a Veteran? *

Yes No
How would you best describe yourself? *

White Asian (Origin: example Chinese; Indian; Afghan; Filipino; Iranian; etc.) Black/African American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Prefer not to answer Other
Are you of Hispanic/Latino/Spanish origin? *

No, not of Hispanic, Latino, or Spanish origin Yes, I am of Hispanic, Latino, or Spanish (Origin: example Mexican, Puerto Rican, Cuban, Dominican, Colombian, Spaniard, Ecuadorian, etc.)
Sports Association Membership
Have you participated in a Gaylord Sports Association Program in the past?

Yes No
If you are not a member of the Sports Association, or have not participated in a program in the last 3 years, please complete a member profile as part of your registration. You may download a member profile form here.
Program Registration
Which classes would you like to register for (select all that apply)?

Mon. Jan 4- Dance Fitness - 6:00-6:45pm Mon. Jan 11 - Mindful Resilience Yoga - 7:00-8:00 PM Tues. Jan 19 - Mobility - 6:00-7:00 PM Mon. Jan 25 - Strength & Conditioning - 6:00-7:00 PM Mon. Feb 1- Chair One Fitness - 6:00-6:30 PM Tues. Feb 9 - Mobility - 6:00-7:00 PM Mon. Feb 15 - Strength & Conditioning - 6:00-7:00 PM Mon. Feb 22 - Mindful Resilience Yoga - 7:00-8:00 PM
What are your goals for participation in this program?
Please indicate if there are specific areas you would like to work on during the strength and conditioning class (select all that apply):

Core Arms Back Legs Chest Grip Strength Other
What type of fitness equipment do you have at home (bands, weights, other)?
Medical Information
What is your primary diagnosis? *

Spinal Cord Injury Traumatic Brain Injury Multiple Sclerosis Stroke Acquired Brain Injury Amputee PTSD Spina Bifida Visual Impairment Other
Please make any additional comments about your disability or medical history that we should be aware of:
Do you have a latex allergy? *

Yes No Not Sure
How did you hear about this program?

Email from the Sports Association Gaylord Employee/Gaylord Therapy Internet Search Other
Do you have any questions or additional information you would like to share?
Liability & Media Waiver
All participants must sign an annual liability waiver and optional media release. Please click HERE to sign the waiver prior to submitting this registration form. Once the liability waiver is signed, please select option 2 if you would like to sign the media release. Then return to this page and submit your registration. Thank you!
Acknowledgment
By submitting this form, I verify that the above information is current and accurate. I understand that the above information will be kept confidential. In order to provide a safe and fun experience your information may be shared with: (1) Sports Association staff, coaches or instructors (2) other adaptive sports programs who will be working with you (3) medical professionals in case of emergency (4) as required for Sports Association grant reports. I understand that it is my responsibility to inform the Sports Association regarding changes to my: (1) contact information such as address, phone and email; (2) medical status including new diagnosis, surgery or medical changes; (3) any other information that is relevant to the safety of myself or others regarding my participation in Sports Association programs.
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Virtual Fitness Series Registration

Participant Information

Sports Association Membership

Program Registration

Medical Information

Liability & Media Waiver

Acknowledgment