Health and Wellness Form

Date

Phone land line(Required)

Cell

Email(Required)

Date of Birth(Required)

Emergency Contact: Name, Relationship, and Phone:

In-person location place:(Required)

Start Date(Required)

Grants Report Information
Grants help make these classes possible at no cost. The information gathered here (not using names) is shared only in grant reports to funders who use it to determine other community needs and consider additional funding opportunities.

Living Arrangement

Other, please specify:(Required)

Group Number

Member ID

Insurance Authorization and Assignment of Benefits:
Some insurance companies are reimbursing for evidence-based health classes that ElderCircle offers. These reimbursements are vital for the long-term sustainability of these classes. Reimbursement from coverage plans requires authorization from class participants. This will not impact your premium, co-pay or deductible.

Authorization Payment Name(Required)

, authorize payment of medical benefits to ElderCircle on my behalf. This will help sustain these classes and keep them free of charge to participants.

Participant Signature(Required)

Date(Required)

Health & Wellness Registration

Stay Connected! Email Signup