StrongBodies Virtual Registration January 2021
Complete this form to enroll.
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I would like to enroll in a Virtual StrongBodies YES: *
Name (First, Last)
County of participation?
Who was your in-person StrongBodies Leader(s) if you participated prior to the pandemic?
What days? Times? did you StrongBodies Class meet? (ie T/Th 9am)
Email Address *
Confirm Email Address *
Demographics: Gender *
Demographics: Race *
Demographics: Ethnicity *
Programs that you and your family participate in: (Check all that apply) (This information is NOT shared and is only used to identify what funding UW-Extension uses for programming. *
Required
How many people live in your household? *
Monthly Household Cash Income (This information is NOT shared and is only used to identify what funding UW-Extension uses for programming. *
Are you in need of hand or ankle weights? (You may be eligible to receive these for free through a grant) *
Disclaimer: I have voluntarily enrolled in this virtual StrongBodies program of progressive exercise. The program is designed to place a gradually increased workload on the heart, lungs, muscles, and bones to help improve their function. I understand that participation in such a program may be associated with some risks. These risks may include but are not limited to: muscle soreness, fainting, disorders of heartbeat, abnormal blood pressure, and in very rare instances, heart attack. To the best of my knowledge, I do not have any limiting physical conditions or disabilities that would preclude an exercise program. I release everyone who has designed, promoted, or conducted the StrongBodies Program from all claims or liabilities whatsoever resulting from my participation in this program. I assume all risks and responsibility for any injury, damage, or any other adverse event that may result from my participation in this program. Before I begin this program, I have already been enrolled in the StrongBodies program in my local community and have abided by their respective registration requirements. I understand that each person may react differently to these fitness activities and these reactions cannot be predicted with complete accuracy. I will inform my Program Leader and/or my health care provider if I experience any unusual symptoms. *
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