Canning Active for Life Registration

Complete this form to register for exercise sessions with the aim of improving the health and fitness of individuals and to promote living a healthy active lifestyle. The main goals of the program are to minimize the impact that chronic conditions have on the human body, and to improve overall health and quality of life of individuals living within the community. The program is supervised and delivered by a Clinical Exercise Physiologist with the Centre of Lifestyle Studies.

Class start: January 17th, 2023 (10 weeks total)

Tuesday & Thursday 9:00-10:00am 

Cost: $60per person or $100 per couple 

Location: Canning Fire Hall - 977 J Jordan Road 

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First and Last Name *
Phone Number *
Email Address *
Age
Emergency Contact Name *
Emergency Contact Phone Number *
Please read the following and sign below to indicate your understanding and agreement: The Canning & District Recreational Commission staff, including those contracted by Canning & District Recreational Commission (referred to as “staff”) is responsible for the supervision of participants during the above registered program(s), which has inherent risks. I, the undersigned, do hereby agree to participate in the stated registered program, and I further agree to indemnify and hold Canning & District Recreational Commission staff harmless from and against any and all liability for any injury which may be suffered by the aforementioned individual arising out of or in any way connected with his/her participation in this program. I further authorize the administration of any first aid steps that may be deemed necessary by qualified personnel.
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Videography/Photography Consent: we occasionally take photos or videos to document programs or activities which could then be used in our educational or promotional materials. Permission is granted for CDRC to use still photographs or videos for this participant for these purposes only.
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I will be paying by: *
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