Exercise for Life

Exercise 4 Life(EX4L) Application
Exercise for Life (EX4L) is a strength and conditioning program for individuals ages 16 and up with a physical disability. The class provides an opportunity to work on building strength, endurance and flexibility in a group setting. The class is run by an exercise specialist under the supervision of a physical therapist. This is an excellent opportunity for participants to learn or build upon fitness skills and become more comfortable working out in a gym setting. Modifications will be made for each individual to promote independence and success. The program is offered in eight week sessions four times per year. The class is offered on Tuesday evenings and Saturday mornings.

2025 Sessions:

Winter: Jan 21 - March 15

Spring: April 15 - June 7

Summer: July 29 - September 20

Fall: October 21 - December 20

Classes are located at Gaylord Physical Therapy in Cheshire
I would like to register for the Exercise for Life Program.*

YesNo
I would like to register for the following session:*

Summer July 29-Sept. 20
Please indicate the class times you are available for (select all that apply). You will be registered for one time slot that you are available for based on class capacity. We will notify you of the date and time prior to the start of the class series*

Tuesdays 6:30-7:30 PMTuesdays 7:30 - 8:30 PMSaturdays 9:00 - 10:00 AMSaturdays 10:00 - 11:00 AM
Participant Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Date of Birth*

MonthDayYear
What is your gender?*

MaleFemaleI prefer not to answer
Are you a Veteran?*

YesNo
Sports Association Membership
Have you participated in a Gaylord Sports Association Program in the past?*

YesNo
If you are not a member of the Sports Association, or have not participated in a program in the last 2 years, please also complete a member profile as part of your registration. Click here for the link to the profile. Once you have finished the member profile, return to this form, complete, and submit.
Program Registration
What are your goals for participation in the EX4L program?*
Have you participated in the EX4L program in the past?*

YesNo
Are you currently participating in a fitness routine?*

YesNo
I currently participate in the following fitness routine(check all that apply):*

Light stretchingYogaLifting weightsWalkingSwimmingCyclingOther
I currently exercise:*

Once per week2-4 times per week5-7 times per week
What types of equipment have you used?(check all that apply)*

Resistance BandsHand weights/DumbbellsExercise bike or other cardio machinesExercise MachinesI have not used any of this equipment
Please provide any additional information and/or any modifications that you may need to support your success. *
Are you cleared by a Doctor to participate in a fitness program?*

YesNo
Are you able to get a Doctor's note if needed to participate in this program?*

YesNo
Medical Information
What is your primary diagnosis?*

Spinal Cord InjuryTraumatic Brain InjuryMultiple SclerosisStrokeAcquired Brain InjuryAmputeePTSDSpina BifidaVisual ImpairmentOther
I currently use the following mobility aid(s)(click all that apply):*

Manual wheelchairPower wheelchairCaneCrutchesRollatorNone
Height*
Weight*
Please make any additional comments about your disability or medical history that we should be aware of: *
If other, please explain:
How did you hear about this program?*

Email from the Sports AssociationGaylord Employee/Gaylord TherapyInternet SearchOther
Do you have any questions or additional information you would like to share?
Acknowledgment
By submitting this form, I verify that the above information is current and accurate. I understand that the above information will be kept confidential. In order to provide a safe and fun experience your information may be shared with: (1) Sports Association staff, coaches or instructors (2) other adaptive sports programs who will be working with you (3) medical professionals in case of emergency (4) as required for Sports Association grant reports. I understand that it is my responsibility to inform the Sports Association regarding changes to my: (1) contact information such as address, phone and email; (2) medical status including new diagnosis, surgery or medical changes; (3) any other information that is relevant to the safety of myself or others regarding my participation in Sports Association programs.
Should be Empty:

Exercise 4 Life(EX4L) Application

Participant Information

Sports Association Membership

Program Registration

Medical Information

Acknowledgment