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!

Bloomfield Senior Center 860-243-8361

Cromwell Senior Center 860-632-3447

Newington Senior & Disabled Center 860-665-8772

Hartford Health & Human Services 860-757-4859

Orange Senior Center 203-891-4789

Plymouth Senior Center 860-585-4031

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

Simsbury Senior Center 860-658-3273

Southington Community YMCA 860-426-9589

Windsor Senior Center 860-285-1881

Woodbridge Senior Center 203-389-3430
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:*

Bloomfield Senior CenterCromwell Senior CenterCheshire Senior CenterGranby Senior CenterHartford Health & Human ServicesNewington S & D CenterOrange Senior CenterPlymouth Senior CenterRegional YMCA Western CTSimsbury Senior CenterRedding - The Heritage CenterSouthington Community YMCAWindham Senior CenterWindsor Senior CenterWoodbridge Center
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Tai Ji Quan: Moving for Better Balance