Strong Willow Elder Membership Form
#Healthback Lets Go!
Please enter a valid phone number.
Date of Birth (Celebrated or the date on Birth Certificate)
Prefer not to answer
Do you have any medical conditions or injuries?
Please share details for any accomodations you may need:
How many months would you like to participate in the Strong Willow Circle?
How many hours per day do you have movement like walking or taking grandkids to park and active play?
More than 6 hour
Please list the goals according to your priority. (First 3 option will be prioritized.)
Stress impacts each one of us different. Our levels of sensitivity are different depending on how we cope. Please share a little about yourself here:
Please share here about your community or family needs. (Optional)
If you want to add your current picture or any relevant documents, please upload here.
Drag and drop files here
Choose a file
If you have a walking or health routine right now, please share it.
Please share your motivation, obstacles, etc. for being in the group. Any concerns or unsafe people for you in community can be listed here. We are doing our best to ensure a brave and safe place so let us know what that looks like for you!
How motivated are you to change health habits in your life?
1 is Not much, 5 is Very
Should be Empty: