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2024 ACCESS Fit Community Registration

Please complete all of the following questions below ...

ACCESS Fit has two community sessions available: Tuesday and Thursday 2:30pm - 3:30pm and Tuesday and Thursday 4:00pm - 5:00pm. Please select one. *

PARTICIPANT INFORMATION

Participant First Name *

Participant Last Name *

Address 1 *

Address 2

City *

State/Province *

Zip *

Gender *

Participant Birthday

// (mm/dd/yyyy)

Participant Age *

Participant Diagnosis *

Have your ever experienced any of the following medical conditions? *

High Blood Pressure
Stroke
Seizure
Heart Murmur
Heart Attack
Severe Allergies
Arthritis
Asthma
Diabetes
Other, Please List:

Other (Medical Condition)

What type of assistive device do you utilize? *

Manual Wheelchair
Power Wheelchair
Walker
Crutches
Hearing Aids
Visual Mobility Cane
Prosthetic Device
None
Other, Please List:

Other (Assistive Device)

What can the ACCESS Fit Staff and Volunteers do to make you/your participant most successful at ACCESS Fit? Please select all that apply. *

Low Music Volume
Verbal Cues
Physical Assistance
Adapted equipment for grip
Visual Schedule/Board
Minimize Distractions
None
Other; Please Enter Below

Other

What Fitness Activities, Sports, and/or Games does your participant enjoy? Please list all interests below. *

Please list any additional information for ACCESS staff to ensure the safety of you/your participant and others. *

PARENT/GUARDIAN INFORMATION

Parent/Guardian First & Last Name *

Parent/Guardian Primary Phone *

Parent/Guardian Primary Email *

Do you receive the monthly ACCESS of Wilmington newsletter? *

Would you like to receive the monthly ACCESS of Wilmington newsletter? *

Is there anyone else you would like us to add to the monthly ACCESS of Wilmington newsletter list so they can receive updates? If so, please provide their First and Last Name and Email below.

First and Last Name

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2024 ACCESS Fit Community Registration

PARTICIPANT INFORMATION

PARENT/GUARDIAN INFORMATION