CBAC ACTIVITY REGISTRATION FORM
Registration fee: All classes - $20, EXCEPT Art Class - $25
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Please check any activities shown below that you are interested in participating:
*
Chair Yoga
Soca Fitness
Line Dance
Computer Beginners
Computer Intermidiate
French Conversation Class
Art
Zumba
Folk Dance
Handicraft & Knitting (FREE)
Have you any experience with the activity of your choice?
Yes
No
All information is confidential. Please check any medical/physical conditions shown below, if applicable:
*
High Blood Pressure
Low Blood Pressure
Wrist problems
Injuries
Arthritis
Back problems
Heart problems
Dizziness
joint Replacement
Are you presently under the care of a physician for any of these issues?
*
Yes
No
If Yes, is your physician aware of your participation in the class?
*
Yes
No
In case of emergency, please give reference of any two people you would like to be contacted:
*
Rows
Full Name
Address
Contact Number
1
2
For returning participants: Suggestions if any for further improvement:
PAYMENT OPTIONS
*
Please Select
PAY BY CASH/CHEQUE - at CBAC CENTER
SEND E-TRANSFER TO cbacmtl@gmail.com
Signature
Submit
Should be Empty: