TCAFP Gravity Forms - Healthy Aging NC

Tai Chi for Arthritis and Fall Prevention Program Registration Form

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:*
MM slash DD slash YYYY

TCA / FP Certified Training Part 2

This workshop is designed with New TCAFP Part 2 Instructors in mind, so we will be providing the equivalent of 1 day without the eye strain.

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address if different from mailing address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Emergency Contact(Required)

First Last

Contact Relationship(Required)

Emergency Contact Phone(Required)

New or Recert?(Required)

New Certification

Recertification

Agency Affiliation(Required)

Name of AAA, Senior Center, other.

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TCAFP Instructor Training & Recertification

This training is supported by an ACL falls prevention grant to the NC Center for Health and Wellness at UNC Asheville, which also funds a partnership with the Healthy Aging NC Tai Chi for Arthritis and Fall Prevention Training Academy at the High Country Area Agency on Aging.

Name(Required)

First Last

Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Emergency Contact(Required)

First Last

Contact Relationship(Required)

Emergency Contact Phone(Required)

New or Recert?(Required)

New Instructor (I will need access to the Stage 1 self-paced program and commit to completing prior to attending the live sessions.) Cost: $160

Recertifying, but have not taught in 2 years or more (I will need access to the Stage 1 self-paced program and commit to completing prior to attending the live sessions.) Cost: $160

Recertifying TCAFP Part 1 only, Cost: $75

Recertifying TCAFP Part 2 only, Cost: $75

Recertifying both TCAFP Part 1 & 2, Cost: $125

Agency Affiliation(Required)

Name of AAA, Senior Center, other.

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Tai Chi for Arthritis & Fall Prevention Recertification Only

Name(Required)

First Last

Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Emergency Contact(Required)

First Last

Contact Relationship(Required)

Emergency Contact Phone(Required)

Recert Type?(Required)

Recertifying TCAFP, Cost: $75

Recertifying both TCAFP Part 1 & 2, Cost: $125

Agency Affiliation(Required)

Name of AAA, Senior Center, other.

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TCAFP Instructor Training & Recertification Part 2 and New

Name(Required)

First Last

Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Emergency Contact(Required)

First Last

Contact Relationship(Required)

Emergency Contact Phone(Required)

New or Recert?(Required)

Part 2: New Instructor, Cost: $160

Recertifying TCAFP Part 2 only, Cost: $75

Recertifying both TCAFP Part 1 & 2, Cost: $125

Agency Affiliation(Required)

Name of AAA, Senior Center, other.

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