Skip to content
Accessibility tools
Search
Increase/Decrease Font Size
a
A
High Contrast: White Background with Black Text
Menu
Home
About
Advocacy
Area Plan
Partners
Programs & Services
Care Coordination
Caregiver Support
Care Transitions
Dementia & Memory Loss
Family Raising Family: Kinship Caregiver
Information & Assistance
Medicaid In-Home Care
Medicare
Nutrition Assistance
Preventing Falls
Support Services in the Home & Community
Opportunities
Careers
Contracting Service Opportunities
Become a Caregiver
Volunteer
Community Living Connections
Dementia Friendly Community
Falls Prevention
Planning & Management Council
Senior Assistance Fund of Eastern Washington
Statewide Health Insurance Benefits Advisors
News & Events
Event Calendar
News
Contact Us
Contact Us
Directions
Vulnerable Adult Concerns
Additional Resources
A Matter of Balance, Class Registration Form
Name:
(Required)
First
Last
Phone:
(Required)
Email:
(Required)
Address:
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Class Location / Area Requested:
(Required)
How did you learn about the class/program?
(Required)
Make a selection
Website / Google Search
Community Event
Community Presentation
Telephone Book
Meal site
Newspaper Ad
Newspaper Article
Radio Ad
Doctor / PT / Medical Clinic
Senior / Community Center
Family Member / Friendā¦
Other
How did you learn about the class/program? - Other
(Required)
Please answer the following questions about your recent experience with falls.
Have you fallen in the past year?
(Required)
Yes
No
If yes, how many times?
(Required)
Were you injured?
(Required)
Yes
No
Do you feel unsteady when standing or walking?
(Required)
Yes
No
Do you worry about falling?
(Required)
Yes
No
How would you like your confirmation sent?
(Required)
Email
Mail
Δ
x
