Contact Lorrie at:

Active Options
P.O.Box 2780
New Liskeard, ON, P0J 1P0.
Phone: 705-647-2848 or
E-mail at activeoptions@ntl.sympatico.ca.

1) If you have not completed a Client Information/Consent Form for Active Options - Please complete the form below. Once you have completed and submitted the form, please click on Book Online to book and pay for your classes or to purchase a class card. If you prefer not to pay online then you can complete the Client Information/Consent Form and submit it online and bring your payment to class.

2) If you have already completed the Client Information/Consent Form for previous Active Options classes please go directly to the Book Online page where you will find the Class Descriptions and Payment Options.

Client Information/Consent Form

->>Click here for printable version of Registration and Consent Form

The following information will be kept private and confidential. It will not be shared, sold or traded. Please keep us informed of any changes.

Name:
Mailing Address
City:
Postal Code:
Tel(H):
Tel(W):
E-mail:
Date of Birth:
Occupation:
Past Exercise (yoga, strength training, walking, pilates):
How Long?:
What do you hope to gain through participation in this program?
Do any of the following apply to you?
Arthritis	Hernia
Asthma/breathing problems	High blood pressure
Cigarette smoking	Kidney/ bladder
Diabetes	Menopause
Digestive problems / colitis / diarrhea	Osteoporosis
Eye problems / glaucoma / detached retina	PMS
Fatigue / sleep disorders	Pregnant – Due date:
Hearing / ear problems	Recent surgery
Heart condition	Thyroid
IBS	Other?:
Numbness / pain in:
neck shoulders elbows hands wrists hips lower back upper back
knees ankles feet other (please note):
Is there any other reason why you should limit your physical activity? (ie. Other medication, physical conditions):
Are you currently being treated for any of these conditions?:
By Whom?
Physician Physiotherapist Chiropractor Naturopath
Massage Therapist Other, please specify:
Name of Practitioner:
Please list any prescribed medication you are taking on a regular basis, its purpose and how it affects you.
Please indicate the class or classes in which you would like to register
Monday - CardiacRehab Program 1:00-2:15 p.m P/F Centre Monday - Mindful Movement (Level 1) 11:05 – 11:50 Balanced Motion Tues - Building Bones (All Levels) 11:00–12:00 P/F Centre Tues - Noon Hour Yoga & Pilates (All Levels) 12:00 – 1:00 P/F Centre Tues - Yoga (Level 1) 4:30 – 5:30 Balanced Motion Wed - Sunrise Yoga & Pilates (Level 2) 6:45 – 7:45 am P/F Centre Wed - Men’s Yoga Stretch (Level 1) 8:30 – 9:30 am Balanced Motion Thurs - Restorative Yoga (All Levels) 9:30 –10:30 am Balanced Motion Thurs - Building Bones (All Levels) 11:00 – noon P/F Centre Thurs - Yoga & Pilates (All Levels) 4:30 – 5:30 P/F Centre Thurs - CardiacRehab Program 1:00 - 2:15 pm P/F Centre (Level 2) 10:30 - Noon P/F Centre
Yes, I agree to the above.

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