Senior Wellness Classes Pre-Registration Form

Senior Wellness Classes Pre-Registration Form
The completion of this form requires no obligation on the part of the applicant nor the management. It does establish an interest and eligibility. The information provided will be kept confidential. Please complete all information and return to Ursuline Center, 4250 Shields Road, Canfield, OH 44406, or email to Sister Nancy Pawlen at nancyposu@yahoo.com.

All participants in our classes must be pre-registered. Walk-ins are not permitted. In-person registration is available at the Ursuline Center. Please call (330) 799-4941 ext. 351. Participants will be notified of the date their classes will begin at the in-person registration.

Classes are $10 each, except for those who have an insurance benefit. See below. All participants pay a $30 Facility Fee collected quarterly (January/April/July/October).

Find our full class schedule and class openings on our website at https://www.ursulinesistersmission.org/programs/ursuline-sisters-senior-living/senior-wellness/.
REGISTRANT’S INFORMATION
Name

First NameLast Name
Sex
Date of Birth

MonthDayYear
Date
Street Address
Street Address Line 2
City
State
Zip
Email
example@example.com
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
INSURANCE FRINGES FOR FITNESS PROGRAM
Silver Sneakers?
#
Renew Active?
#
Active and Fit?
#
Self-Pay?
Should be Empty: