Exercise Class Attendance Form

Please take a moment if you have a SilverSneakers or Silver & Fit membership with the Whitney Senior Center. We will submit your attendance for reimbursement to help pay for the instructor's time. Thank you. If you do not have insurance, consider making a donation.

If you have any questions, please feel free to give Paula a call at 320-255-7265.

Reminder - if you have not filled out a Fitness Waiver to participate in the classes, please go back to the newsletter to find the link to fill it out.
Name

First Name Last Name
E-mail
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please Note --If you do not have the SilverSneakers or Silver & Fit set up with the Whitney Senior Center and would like to go ahead and set up- please call our Front Desk M-F 8:00am to 4:30pm to provide your Birthdate and SilverSneakers number to set up by calling 320-255-7245.
Please Mark the dates you attended a Virtual Class to include Senior Yoga, SAIL, Pilates, and Tai Ji *

Tues, Dec 1 Wed, Dec 2 Thur, Dec 3 Fri, Dec 4 Sat, Dec 5 Mon, Dec 7 Tues, Dec 8 Wed, Dec 9 Thur, Dec 10 Fri, Dec 11 Sat, Dec 12 Mon, Dec 14 Tues, Dec 15 Wed, Dec 16 Thur, Dec 17 Fri, Dec 18 Sat, Dec 19 Mon, Dec 21 Tues, Dec 22 Wed, Dec 23 Sat, Dec 26 Mon, Dec 28 Tues, Dec 29 Wed, Dec 30 Thurs, Dec 31
Please write any comments here.
Please use your cursor or fingertip on touchable screen to sign to confirm the above dates you selected. Whitney will submit appropriately to SilverSneakers or Silver & Fit.
Signature

Clear
Signature date
Should be Empty: