TJQ:MBB Participant Waiver & Registration

Tai Ji Quan: Moving for Better Balance

Participant Waiver, Registration and Emergency Card
Name*

First NameLast Name
The site will contact you directly to confirm your registration!

Some locations charge a nominal fee for the class. Any fees will be collected by the location directly. This form is for registration only.

Please feel free to call your site directly if you have questions!

Bethel Senior Center 203-792-3048

Brookfield Senior Center - PLEASE Call the Center 203-775-5308 before registering

Canoe Brook Center 203-315-0683

Cheshire Senior Center -REGISTRATION FOR THIS SITE IS CLOSED AS OF 10/6/2022.

Cromwell Senior Center 860-632-3447

Glastonbury Senior Center 860-652-7646

Granby Senior Center 860-844-5352

Groton Thrive 55+ 860-441-6636

Regional YMCA of Western CT, Brookfield 203-775-4444

Simsbury Senior Center 860-658-3273

Sullivan Senior Center, Torrington 860-489-2211

Southington Community YMCA 860-426-9589

Westport Center for Senior Activities 203-341-5096

Wilton Senior Center 203-834-6240

Windsor Senior Center 860-285-1881

The Woodbridge Center - REGISTRATION FOR THIS SITE IS CLOSED AS OF 10/28/2022.

Woodbury Senior Center 203-841-6161
Your Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
If you are registering for a VIRTUAL program, and you will be exercising from a location that is NOT your home address listed above, please list that address here for emergency purposes. If you are participating in the class in person at the center or at your home address, you can skip this question.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*

First NameLast Name
Daytime phone number for Emergency Contact *
Please enter a valid phone number.
Do you have any physical limitations? If yes, please explain. *
In the past year, have you had any hospitalizations or emergency room visits for serious health problem(s) that might affect your ability to participate in this exercise program?*

YesNo
If you answered yes above, please explain.
Today's Date*

MonthDayYear
By typing your name below, you take full responsibility for your voluntary participation in the Tai Ji Quan: Moving for Better Balance class being offered at the site listed below. You agree to be gentle and work at your own capacity in the class and when practicing outside of class time. You release the site, the instructor, CT Community Care, The CT Healthy Living Collective, Fuzhong Li, Ph.D., Exercise Alternatives, LLC and the Oregon Research Institute from liability resulting from any injury or discomfort from your attendance and participation.

You also agree that Connecticut Community Care Inc., CT Healthy Living Collective and the program location listed above, their employees agents or representatives, may photograph you with television, video, movie or still camera. The pictures and any statements or voice recordings made at the time of photography or in connection with the photography may be processed in any manner and by whatever method or combination of methods elected. Furthermore, you agree to waive any right or claim you might have to any compensation, fees or other benefits by use or reuse of the video/photograph and the undersigned hereby releases the organizers from any claim or demands for compensation or liability arising from said use of or publication of said pictures anywhere in perpetuity. By providing your contact information you consent to receiving correspondence via mail or email from the CT Healthy Living Collective (CHLC) regarding future CHLC programs.
Sign or Type your name here to agree to the above:*
Please select the Senior Center or other organization that you registered with for the Tai Ji Quan: Moving for Better Balance program:*

Bethel Senior CenterBrookfield Senior CenterRegional YMCA Western CTSouthington Community YMCAThe Woodbridge Center REGISTRATION CLOSED AS OF 10/28/22Cromwell Senior CenterCheshire Senior Center REGISTRATION CLOSED AS OF 10/6/2022Simsbury Senior CenterSullivan Senior Center, TorringtonWestport Center for Senior ActivitiesGranby Senior CenterSouthington Community YMCAGroton Thrive 55+Glastonbury Senior CenterCanoe Brook BranfordWindsor Senior CenterWilton Senior CenterWoodbury Senior CenterOther
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Tai Ji Quan: Moving for Better Balance