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
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