Wellness Connect & Care Walking Group Participant Registration

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Description

Walking groups are volunteer-led and for ALL seniors! The groups promote physical and mental health, provide opportunities to connect with others and form friendships. Since the groups are dementia friendly, those impacted by dementia have the opportunity to share and stay engaged in the community, and maintain social connections in a supportive environment.

*Walks are subject to cancellation or postponing due to weather
*Walks are subject to location change

Participant 1 - First & Last Name *

Is this registration for yourself or another person?

For myself

For another person who will walk with me

For another person who will walk on their own

Clear selection

Phone Number *

Age range of the walker being registered *

Under 25

Ages 25-34

Ages 35-44

Ages 45-54

Ages 55- 64

Ages 65+

Self-identified gender of the walker being registered: *

Male

Female

Other

Prefer not to disclose

Which of the following walks are you registering for?

Charlottetown - Saturdays & Tuesdays 9:45am-11am

O'Leary - Fridays, 1:00-2:00pm

Montague - Thursdays, 8:50-10:00am (on hold until Spring)

Which of the following apply to you, or the person you are registering?

I have a medical concern that may impact my participation in a walking group

I have mobility issues that need to be accommodated to ensure my participation in a walking group

I have other specific safety concerns to address regarding my participation in a walking group

I have a cognitive impairment or diagnosis of Alzheimer's or dementia

Other:

If you indicated that you have mobility issues, which of the following apply?

I require an assistive device (cane, walker or wheelchair)

I am at risk of falling (balance, weakness, vision or other problems)

I can only walk short distances

I can only walk at a slower pace

I require assistance when walking (person)

Other:

I grant permission to share any of my medical or mobility conditions that may impact my safety and participation in this group with the volunteer walking group leaders.

Yes

Clear selection

Emergency Contact Name *

Emergency Contact Phone Number *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of alzpei.ca. Report Abuse

Forms