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2. The LPR Health & Wellness Division is offering an evidence-based wellness program designed specifically for the residents of the Bluebirds of LIberty.

    PROGRAM INFORMATION:

   BINGOcize- Falls Prevention 

   • Session Dates: April 15 - July 3
   • Days: Tuesdays & Thursday 
   • Time: 1:00 p.m.-2:00 p.m.
   • Registration required-limited class size
   • Registration deadline is April 14
4. First Name*
5. Last Name*
7. Date of Birth*
   Date of Birth
9. Email Address*
11. Phone Number*
12. Phone type *

    1. Cell
    2. Home
14. Home Address*
16. Gender*

    1. Male
    2. Female
    3. Prefer not to share
17. Number of people in your household
19. Is English the primary language you speak?

    1. Yes
    2. No
    3. Prefer not to share
20. Primary race
22. Ethnicity

    1. Hispanic
    2. Non- hispanic
23. Military Service or spouse of a Veteran?

    1. I am active duty military
    2. My spouse is active duty military
    3. I am a veteran
    4. My spouse is a Veteran
    5. None of these apply to me
25. Participation Waiver
    I am over the age of 18 and acknowledge I have been informed of the need for a physician’s approval for my participation in wellness programming. I acknowledge I have either had a physical examination and been given my physician’s permission to participate, or if I have chosen not to obtain a physician’s permission prior to beginning this program, I acknowledge I am doing so at my own risk.
    
    I understand and am aware that health and wellness programming includes potentially risky activities. I am voluntarily participating in these activities with knowledge of the potential risks. I hereby agree to hold harmless Liberty Parks & Recreation, its respective representatives, executors, agents, and assigns from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected to my participation in any and all wellness programming.
    
    I acknowledge I have thoroughly read this waiver and release and fully understand it is a waiver and release of liability. By signing this document, I am waiving any right I, or my heirs and/or assigns, may have to bring any and all legal actions or assert any and all claims against Liberty Parks & Recreation, its respective representatives, executors, and/or assigns.
    
    * I have read the above information and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
27. Acknowledgement*

    1. I Agree
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29. Submit

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