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About
Get Involved
Home Support
Community Programs
Calendar
Contact
Blogs

Registration

Fill out the form and get started with any of our classes and programs

Community Programs

Registration Form

By submitting this form, I agree that all included information is correct. I also consent to information sharing, collection and disclosure of my personal information in order to facilitate the provision of care and services for myself with MSC and Stonebridge personnel, authorized designate and or emergency contacts. I agree to contact the office immediately if there are any changes to the information supplied in this form, to ensure my records stay up to date. Confidentiality is guaranteed by both Stonebridge and the MSC.

The MSC and Stonebridge are committed to safeguarding your personal information. We are governed by the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Personal Health Information Protection Act (PHIPA).

"*" indicates required fields

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Personal Information

Name*

First Last

Phone Number*

Date of Birth*

MM slash DD slash YYYY

Email*

Address*

Street Address Address Line 2 City Province Postal Code

Program Preference

Pickleball

Exercise & Fall Prevention

Urban Poling & Walking Club

Preferred Exercise Location*

Emergency Contact Name*

Emergency Contact Phone Number*

Physical Activity Readiness Questionnaire

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor?*

Yes

Do you feel pain in your chest when you do physical activity?*

Yes

In the past month, have you had chest pain when you were not doing physical activity?*

Yes

Do you ever lose balance because of dizziness?*

Yes

Do you ever lose consciousness?*

Yes

Is your doctor currently prescribing medication for your blood pressure?*

Yes

Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

Yes

Is your doctor currently prescribing medication for a heart condition?*

Yes

Do you know of any reason why you should not do physical activity?*

Yes

Please feel free to note any additional information that you feel would be helpful for us to know. If you answered YES to one or more of the questions, or if you are over the age of 69 years of age and are not used to being physically active, please talk to your doctor before you become much more physically active.

Falls Prevention

Have you fallen in the past 6 months?*

Yes

If so, please indicate the number of falls you have had:

Do you currently use a mobility device such as a cane, walker, walking poles?*

Yes

Please find the Liability Statement below.*

I have read and agree to the liability statement.

Liability Statement

Do you acknowledge and understand that there are risks associated with participation in any exercise class?
Being aware of these hazards, do you voluntarily elect to participate in the group exercise class offered by Multi-Service Centre, in partnership with Stonebridge Community Services and fully accept and assume all risks and responsibilities for any injury, loss and/or damage to persons or property that you incur as a result of your participation?
If at any time you feel your physical condition no longer allows you to safely participate in the exercise class or if you believe that the class becomes unsafe, do you agree to stop your participation immediately?
For the safety of all participants, do you agree to forgo coming to class on any day that you are feeling unwell (for example cough, sore throat, fever or any other physical signs of being unwell)?
Do you agree to wear a mask when arriving at and leaving an exercise class and to maintain a physical distance of 6 feet while participating in the group exercise class?
Do you agree to wash your hands or use hand sanitizer upon arrival at the group exercise class?

Email Sign Up

I agree to receive future communications from Stonebridge Community Services

Stonbebridge/MSC is committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified; (health history, contact information, personal opinions) you can be assured that it will only be used in accordance with the Stonebridge/MSC privacy policies, program policies and applicable laws, legislations and contractual agreements.

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We’d like to thank and recognize our partners and funders in the community.

Stonebridge Community Services
Inside the Livingston Centre
96 Tillson Ave, Tillsonburg ON, N4G 3A1
519-842-3200
TOLL FREE: 1-855-842-3200
[email protected]

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Stonebridge Community Services is a not for profit organization providing in-home health care and preventative health services designed to help people maintain good health and independence through the aging process. Stonebridge services are available to everyone in the community and are designed to enhance or support a wide range of health services.

Monday to Friday: 8:30am to 4:30pm