Steady for Life | Registration Form

REGISTRATION - PLEASE PRINT

My Class Location is:

Name
Address
City		Zip
Home Phone	Mobile Phone
Email		Birth Date
Emergency Contact	Relationship
Contact Phone Home	Contact Phone Mobile
Primary Physician	Phone

WHAT IS YOUR PREFERENCE FOR COMMUNICATION (Circle)?

PHONE
TEXT
EMAIL

HOW DID YOU LEARN ABOUT STEADY FOR LIFE:

WHICH CLASS(ES) WILL YOU BE TAKING? (Circle)

BALANCED BODY 1	BALANCED BODY 2	BALANCED BODY 3	REV IT UP! BALANCE	PILATES	GENTLE YOGA	INTERMEDIATE YOGA	CHAIR YOGA
ZOOM BALANCED BODY 1	ZOOM BALANCED BODY 2	ZOOM BALANCED BODY 3	ZOOM REV IT UP! BALANCE	MOVE TO THE MUSIC (ZUMBA)	MOVE TO THE MUSIC (LINE DANCING)	STRENGTH BUILDING

LIST ANY PHYSICAL LIMITATIONS OR MAJOR HEALTH CONCERNS THAT AFFECT YOUR BALANCE:

By signing below, I hold no one liable in case of injury while participating in the Steady for Life Balance program or participating in any Steady for Life events outside of class.

Signature:

Date:

Revised 3/2024