Stepping On Workshop
A fall prevention program called "Stepping On" will be offered by the Faith Community Nurses and guest experts for anyone age 60 or over who lives at home, does not have dementia, and has had a fall or is fearful of falling. The workshop will be on Thursdays, 1 pm to 3 pm, each week starting October 5th and ending November 16th.

Please note that there is a $15 fee for this workshop. Please bring the fee to the first session of the workshop. If paying by check, make it payable to First Free Church.

Your name: *
Your answer
Address: *
Your answer
Primary phone number: *
Your answer
Do you use email? *
If yes, your email address:
Your answer
Do you live in a house or apartment? (Note: if your answer is no, this workshop may not be appropriate for you. Consider talking to your doctor about having a falls assessment and other methods of preventing falls) *
Are you able to walk without the help of another person? (Note: if your answer is no, this workshop may not be appropriate for you.) *
Do you use a walker, scooter, or wheelchair most of the time indoors? (Note: if you need assistance with a walker, scooter, or wheelchair most of the time when walking indoors, this workshop may not be appropriate for you.) *
Have you fallen in the past year? *
If yes, how many times? (If you have fallen six or more times in the past year, consider talking with your doctor about whether you may benefit from additional individualized assessment or intervention.)
Your answer
Do you have any problems with your vision? *
If yes, please describe what we'd need to do to accommodate your needs in the workshop.
Your answer
Do you have problems with your hearing? *
If yes, please describe what we'd need to do to accommodate your needs in the workshop.
Your answer
CONSENT TO USE IMAGE FOR QUALITY ASSURANCE, EDUCATIONAL OR PROMOTIONAL PURPOSES: By checking the box below, I voluntarily consent to and authorize all persons associated with the Wisconsin Institute for Healthy Aging (WIHA) to videotape or otherwise photograph or record my voice or image in this workshop for quality assurance, promotional or educational purposes only, including use in training manuals and on websites and brochures. Neither my name, nor any other identifying information will be provided unless I provide specific separate consent. I waive any right to inspect or approve the videotape or any of the other photography or recordings or to receive any compensation for my participation.
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