Contact Lorrie at: Active Options P.O.Box 2780 New Liskeard, ON, P0J 1P0. Phone: 705-647-3048 or E-mail at activeoptions@ntl.sympatico.ca. If you would like to register, please fill in and submit the online form below. There is a printable version available as well that you can mail to the above address. Registration & Release 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 Tuesday 11:00 - 12:00 Building Bones Tuesday Noon Hour Yoga and Pilates Tuesday 4:30-5:30 Beginner Yoga Wednesday 6:45-7:45 a.m. Sunrise Yoga Thursday 9:45 - 10:45 a.m. Building Bones Thursday 11:00 - 12:00 Restorative Yoga Thursday 4:30-5:30 Yoga and Pilates Thursday 4:30-5:30 p.m. Yoga and Pilates ( All Levels) Friday 10:30-Noon Level 2 Yoga and Pilates Yes, I agree to the above. Top of document
Contact Lorrie at: Active Options P.O.Box 2780 New Liskeard, ON, P0J 1P0. Phone: 705-647-3048 or E-mail at activeoptions@ntl.sympatico.ca.
If you would like to register, please fill in and submit the online form below. There is a printable version available as well that you can mail to the above address.
->>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.
Top of document
