Seniors Exercise Class

Name*

First NameLast Name

Address

E-mail*

Please confirm E-Mail.

example@example.com

Home Number

Area CodePhone Number

Mobile Number

Area CodePhone Number

Date of birth

MaleFemale

EnglishFrenchOther

TuesdayThursdayBoth

Country of Origin

Health Card Number including version code

Emergency Contact Person

Relationship

Emergency Contact Phone Number

Area CodePhone Number

YesNo

How did you hear about this program:

Waiver: I hereby release Carefirst (Carefirst Seniors and Community Services Association and Carefirst Foundation and their directors, officers, employees, and agents) and its Service Provider from any claims, damages, costs, expenses or any other liability arising from any injury or damage to my person or property sustained as a result of my participation in any activities held at any location.

Initial

Thank you for registering for our Seniors Exercise Class beginning weekly on Tuesday, March 21 at 10:15 a.m. at Adath Israel.

We look forward to seeing you.