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Zoomers on the Go Registration
Questions?
Contact us at (506) 458-7034 or
cellab@unb.ca
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* Indicates required question
"I have read and understood the disclaimer above. I agree to the terms and agreements."
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Yes
Required
First Name
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Your answer
Last Name
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Your answer
Email Address
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Your answer
Phone number
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Your answer
I am a...
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New participant
Returning participant
Name of class instructor or location of Zoomers class (if known)
Your answer
Date of Submission
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MM
/
DD
/
YYYY
Are you comfortable signing the consent forms through e-mail? (filling out on the computer, or printing and scanning/ taking a picture of documents)
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Yes
I can try (but will provide mailing address just in case)
No
Do you have the equipment needed (exercise ball & resistance band)?
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Yes
No
Other:
Address (to send equipment and/or forms)
Your answer
Emergency contact name and phone number
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Your answer
I am registering for classes:
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In my community
Online
Which community do you reside in, in New Brunswick? (i.e. Fredericton, Boisetown, etc.)
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Your answer
How did you hear about this program?
Facebook
From a friend/ word of mouth
CBC/CTV News
Community board / pamphlets
Zoom in the Sun outreach
Other:
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Get Active Questionnaire
Please complete this brief screening tool below
The following questions will help to ensure that you have a safe physical activity experience. Please answer YES or NO to each question before you become more physically active. If you are unsure about any question, answer YES.
1. Have you experienced ANY of the following (A to F) within the past six months?
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A diagnosis of/treatment for heart disease or stroke, or pain/discomfort/pressure in your chest during activities of daily living or during physical activity?
A diagnosis of/treatment for high blood pressure (BP), or a resting BP of 160/90 mmHg or higher?
Dizziness or lightheadedness during physical activity?
Shortness of breath at rest?
Loss of consciousness/fainting for any reason?
Concussion?
None of the above
Required
2. Do you currently have pain or swelling in any part of your body (such as from an injury, acute flare-up of arthritis, or back pain) that affects your ability to be physically active?
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Yes
No
3. Has a health care provider told you that you should avoid or modify certain types of physical activity?
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Yes
No
4. Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis, asthma, spinal cord injury) that may affect your ability to be physically active?
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Yes
No
During a typical week, on how many days do you do moderate- to vigorous-intensity aerobic physical activity (such as brisk walking, cycling or jogging)?
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Your answer
On days that you do at least moderate-intensity aerobic physical activity (e.g., brisk walking), for how many minutes do you do this activity?
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Your answer
I understand that I will be contacted by a member of the team to complete registration. I understand that filling out this form does not guarantee I will be registered for Zoomers on the Go.
*
Yes
Required
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