Saturday, August 8, 10:00am - 1:00pm

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* 1. Name

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* 3. Phone Number

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* 4. City of Residence

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* 5. What is your age? (optional)

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* 6. Select which health screenings you're interested in.

Fitness classes are available on a first-come, first-served basis. A sign-up sheet will be located at the front desk inside the fitness center for each class. Registration opens 1 hour prior to the start of class.

10:00am - 10:30am: Fall Prevention
10:45am - 11:15am: Chair Yoga
11:30am - 12:00pm: Chair Pilates
12:15pm - 12:45pm: Chair Zumba

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* 7. Are you interested in receiving a senior case management consultation?

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* 8. Are you interested in learning more about the fitness center?

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* 9. How did you learn about this event?

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* 10. Waiver & Release of Liability

By clicking "yes" below, I hereby consent, understand, and/or agree to the following:

1) That I am participating voluntarily in the Age Well Health Fair, which may include access to the Peninsula Health Care District’s Health & Fitness Center and training, programs, exercises, events, and fitness classes offered by the Health & Fitness Center instructors.

2) I understand that it is my responsibility to consult with a physician prior to and regarding my participating in any fitness program. I represent and warrant that I am physically fit and have no medical condition that would prevent my full participation in the exercise programming.

3) I agree to assume full responsibility for all risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the Health Fair and programming offered by the Health & Fitness Center.

4) I knowingly, voluntarily, and expressly waive any claim I may have Peninsula Health Care District and the Health & Fitness Center and their directors, employees, instructors, and volunteers based on my participation in the Age Well Health Fair.

5) I, my heirs or legal representatives' release, waive, discharge any claims against and covenant not to sue Peninsula Health Care District, the Health & Fitness Center, the organizers and service providers of the Age Well Health Fair, and their respective directors, employees, instructors, and volunteers, including claims based on ordinary negligence.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

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* 11. Consent Form for Screenings

By clicking "yes" below, I hereby consent, understand, and/or agree to the following:

1) The health screenings conducted today may include one or more of the following: bone density, lung function test, hepatitis B, dental screening, foot exam, glucose, body mass index, body fat percentage, and/or fitness assessment. I consent to the conduct of these screenings.

2) Peninsula Health Care District, Sonrisas Dental Health, Mills-Peninsula Hospital, Chinese Hospital, Breathe California, HepBFree, their employees and volunteers, and any other organization(s) associated with the screenings are released from any and all liability arising from or in any way connected with the screenings conducted.

3) The screenings are provided as a public service for educational purposes only and no physician/patient or other medical relationship is established.
The results from the screenings do not constitute a medical diagnosis and that it is my responsibility to follow up with my healthcare provider regarding my test results.

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

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