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A Matter of Balance, Class Registration Form
Name:
(Required)
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Last
Phone:
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Email:
(Required)
Address:
(Required)
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Address Line 2
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How did you learn about the class/program?
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Website / Google Search
Community Event
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Newspaper Article
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Doctor / PT / Medical Clinic
Senior / Community Center
Family Member / Friend…
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
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