Young at Heart S.T.E.P.S. Registration 2021-2022

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The information being requested below is only for monitoring and auditing purposes, as required by grant
funding, and is not intended for public dissemination. All information is confidential.

Which 12-Week Walking Challenge are you registering for? *

Spring 2022 STEPS Challenge (Feb. 28th - May 22nd)

Required

Email Address *

Last Name *

First Name *

Phone Number *

Street Address *

City *

State *

Zip Code *

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Age Range *

What is your gender? *

What was your sex at birth?

How do you describe your sexual orientation or sexual identity?

Please Check all that Apply *

Disabled

Veteran

None of the above

Required

Do you receive income from any of the following sources? *

Food Stamps

General Assistance

Supplemental Security Income (SSI)

None of the above

Required

Race *

Select Your Insurance *

If you have HMO/Medicare Advantage Plan, which one do you have?

If you have ONE person in your household please select your total annual household income *

I have more than one person in my household

$15,000 or less

$15,001 - $25,000

$25,001 - $39,950

$39,951 or more

If you have TWO people in your household please answer select your total household income *

I answered the previous questions, I have ONE person in my household

I have more than TWO people in my household

$17,420 or less

$17,421 - $28,550

$28,551 - $45,650

$45,651 or more

If you have THREE people in your household please answer select your total household income *

I answered a previous questions, I have less than THREE people in my household

I have more than THREE people in my household

$21,960 or less

$21,961 - $32,100

$32,101 - $50,350

$50,351 or more

(REQUIRED) CONSENT TO PARTICIPATE IN YOUNG AT HEART S.T.E.P.S. : I hereby certify that the above information is true and correct. I, the undersigned, acknowledge that the Young at Heart class is an exercise class which may involve aerobic activity, resistance training for strength and mobility, as well as stretching and balance. Participation at a class location, with the cable show, home-video, or online via YouTube or any other live class is at my own risk. I understand that I should be seen by a physician before beginning any exercise program to ensure my participation is appropriate. I understand the facilities hosting the classes are doing so on a volunteer basis without compensation and participation at a class at any given location is of my own accord. I also grant full permission to the Healthy Aging Association to use my photograph in any publication or advertising materials. I agree that the Healthy Aging Association, their employees, and agents, shall not be responsible in any way for the content of news media coverage in which the photography authorized herein is used. To agree to the terms above, please type your full name below. *

Please enter today's date, in which you agree to the above terms. *

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