Tai Chi for Arthritis and Fall Prevention Program Registration Form - Healthy Aging NC

Participant Name:*

First Last

Address:*

Street Address Address Line 2 City State ZIP Code

Phone:*

Email:*

Emergency Contact:*

Relationship: (i.e. friend, sister)*

Emergency Contact Telephone:*

Program Guidelines:*

Tai Chi for Arthritis and Fall prevention programs are conducted by certified Tai Chi for Heath Institute instructors and are open to any person, provided they are medically fit, independently mobile and can participate without assistance in the program. Any person with any doubt whether they are medically fit to attend the program is required to have medical clearance from their doctor prior to commencing. The physical exertion required for participation in this the tai chi program would be similar to walking. Programs usually last for forty-five minutes to one hour. Participants are encouraged to rest as needed and to work within their own comfort zone and abilities at all times. Participants are required to do a gentle warm-up exercise at the beginning of program and cool-down exercise at the end.

Acknowledgement of Personal Responsibility & Waiver:*

I have read the Program Guidelines and understand that there is an inherent risk in any exercise activities. I agree to abide by the rules set out by my instructor. In consideration for admission to this program, I hereby: (a) accept full responsibility for and assume the risk of any injuries sustained because of my participation in this program or practice of tai chi; (b) release and hold harmless the North Carolina Center for Health and Wellness, its respective employees and directors, the instructor(s) and all personnel in association with the program for any liabilities, injuries and expenses which may arise as a result of participation in this program, practice or lessons involving tai chi. I know of no medical reasons why I should not participate in this program. I understand that if I do have any medical reasons to not participate in this program, it is my responsibility to obtain a clearance from my doctor prior to starting.

Participant Signature:*

By typing your name in this blank you agree to the waiver.

Date:*