Form

Jacksonville University Relaxation Program Information Form

Please complete form to sign up for a Relaxation Program training.
Today's Date
First Name
Last Name
JU Student ID Number
Phone
Prefer to be Contacted By:

Phone E-mail
Student Status

Freshman Sophomore Junior Senior Graduate Student
Racial/Ethnic Background:

African American/Black Asian Caucasian/White Hispanic/Latino (a) Other
College/School:

Arts & Sciences Business Fine Arts Education Nursing Orthodontics Marine Science Institute Undecided/Other
International Student

Yes No
If so, what country are you from?
Are you a JU Athlete?

Yes No
If so, what sport?
Are you a member of ROTC

Yes No
Are you a Commuter Student?

Yes No
As we look to tailor our training to you and get to know you better is there anything else you are comfortable in sharing that is meaningful to you (e.g., ethnic cultural background, religious affiliation, sexual orientation, physical ability/disability, etc.) Please list:
How did you hear about the JU Relaxation Program and Massage Chair?

Community Advisor/Residential Life Friend/Relative Brochure/Printed Material Workshop/Training Faculty/Staff Website Academic Advisor Facebook Other
If referred by a particular faculty or staff member, who was it?
Are you coming to the Relaxation Room as part of a class assignment or extra credit?

Yes No
If so, what class and professor?
Do you have any physical health problems?

Yes No
If yes, please describe:
Which aspects of the Relaxation Program are you interested in:

Biofeedback Massage Chair Both
What relaxation/stress management strategies do you currently use?
What days and times are you usually available?
Are you interested in joining a relaxation group or learning about additional trainings?

Yes No
Should be Empty:

Jacksonville University Relaxation Program Information Form