Caregivers Corner: Wellness Series

Caregivers Corner: Wellness Series

This information will be used in the event a Caregivers Corner: Wellness Series session has to be rescheduled or cancelled. Please complete this form once per person who will attend the group.
Participant Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Cell Phone
Home Phone
E-mail*
example@example.com
Select a session you would like to attend*
Enhancing Health Through Fitness With Brock University (In Person)

Date: Monday, November 17, 2025
Time: 2:30 pm - 4:00 pm
Place: Canada Games Park (2021 Canada Games Way, Thorold, ON L2V 4Y6)

Participate in an exercise class and learn more about the Brock Functional Inclusive Training (Bfit) program through Brock University which aims to improve overall health and enhance quality of life through exercise and activity. No experience needed and all abilities are welcome.

Free and accessible parking available.
Do you require transportation?*

YesNo
Are you a returning friend who has registered for an Alzheimer Society of Niagara Region program in the past (including support groups)?*

YesNoUnsure
The Alzheimer Society Niagara Region is committed to providing the highest quality of support and services to our community. To help us understand better the population we serve, we are requesting additional demographic information. Gathering this information not only helps us tailor our programs to meet the unique needs of our community, but it also plays a crucial role in our ability to apply for and receive funding through Ontario Health and private grants, which require detailed demographic data to support our initiatives. As a healthcare custodian, we are responsible for collecting, managing, and protecting this information in compliance with all applicable privacy standards. Your participation in providing this data helps ensure that we can continue delivering effective, person-centered care to those impacted by dementia.

If you prefer not to answer a specific question, you may choose that option in the questions drop box.
Language Spoken at home
Mother Tongue
Gender
Racial or Ethnic Group
Date of Birth

MonthDayYear
Date
Health Card Number
Health Card Version
Disclaimer

This information will be used for statistical purposes and will be stored on our electronic database; it will be kept confidential and will not be shared outside of our organization. I freely consent to participate in the offered program that will be led by an Alzheimer Society staff member or volunteer. I acknowledge that it is my choice to participate in this activity and I understand that I am free to withdraw from, reduce or modify my involvement in any part of this activity. For programs where food is served, I understand that the organization can only serve store bought, pre-packaged foods, and cannot guarantee an allergen-free environment. I understand the Alzheimer Society of Niagara Region has taken reasonable safety precautions, including following Ontario Public Health recommendations, as a response to Covid-19. I agree to indemnify and hold the Alzheimer Society of Niagara Region harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement. In the event that a program session must be cancelled due to unforeseen circumstances, we will attempt to contact you if given permission above. Participants are encouraged to phone the Alzheimer Society of Niagara Region regarding program changes.
Accept disclaimer:*

I acceptI do not accept
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