MOB Participant Registration & Waiver

Information provided on this form is important for funding to continue to provide services to older adults. Please take the time to answer all the questions on this form. Your personal privacy is very important to us. The law prohibits sharing any information you give without a court order or without permission from you or your personal representative EXCEPT for the following: state, federal and local monitoring relative to program reporting requirements; program management, public safety and research. Be assured that your information will only be used as necessary under those provisions.

Participant's Name *

First Name Last Name

Participant's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

If this program is delivered virtually, is the address above where you will be located when you participate in the class?

Yes No

If you answered "no" in the question above, please indicate where you will be located when you participate in the class.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Participant's Birthdate

Month Day Year

Participant's Email *

example@example.com

Participant's Phone Number *

Please enter a valid phone number.

EMERGENCY CONTACT INFORMATION

Emergency Contact Name *

First Name Last Name

Daytime Phone Number for Emergency Contact *

Please enter a valid phone number.

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) AND YOU

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is safe for most people. However, some people should check with their doctor before they start becoming more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not accustomed to being very active, check with your doctor.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly by checking YES or NO.

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?

If you answered YES to one or more questions - talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.

You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of acivities you wish to participate in and follow his/her advice.
Find out which community programs are safe and helpful for you.

If you answered NO to all PAR-Q qeustions, you can be reasonably sure that you can:

Start becoming much more physically active - begin slowly and build up gradually. This is the safest and easiest way to go.
Take part in a fitness appraisal - this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.

You should DELAY becoming more active if you are not feeling well because of a temporary illness such as a cold or fever - wait until you feel better.

If your health changes so that you then answer YES to any of the questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

The PAR-Q and YOU is a copyrighted, pre-exercise screen owned by the Canadian Society of Exercise Physiology.

Please read and place a check mark next to each statement.

Sign or Type your name here to agree to the above: *

Today's Date *

Month Day Year

Please select your Senior Center: *

Avon Senior Center Glastonbury Senior Center Granby Senior Center Newington Senior & Disabled Center Russell Mercier Senior Center, Hebron South Windsor Senior Center Bloomfield Senior Center Other

Matter of Balance