BREAST CANCER ACTION
Fit & Fab Program
2015/2016 Registration & Waiver
All participants must register in order to attend by filling out both this form (ONE ANNUALLY) and a session choice
form and returning them both to BCA.
1 signed waiver required for each participant for the 2015/16 year & will be kept on file until Aug. 31, 2016.
Participant: _________________________________________________________________________
Telephone: __________________________________________________________________________
E-mail: _______________________________________________________________________
Are you currently a member in good standing of Breast Cancer Action?
_____ YES
_____ NO
In what year were you diagnosed with breast cancer? ________________________
Emergency Contact Information
Name:
____________________________________________________________
Telephone:
____________________________________________________________
Eligibility
BCA fitness classes are open to anyone who has had a breast cancer diagnosis (before, during or after treatment,
including surgery—after first checking with your healthcare provider).
Medical Information
Are you currently receiving treatment for any condition that may affect your ability to exercise?
_____ YES
_____ NO
If yes, please explain: _____________________________________________________________________________
Please list any allergies, medications, chronic illness or other conditions we should be aware of:
___________________________________________________________________________________________
Mandatory Participant Waiver and Release of All Claims
I understand that my participation in this class is voluntary and at my own risk. I take responsibility for any activity I elect to
participate in. I acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries
including death, damages or loss regardless of severity which I may sustain as a result of participating in any and all activities
connected with/associated with these classes. I agree to waive and relinquish all claims I may have as a result of participating
in the program against Breast Cancer Action (BCA) and all officers, agents, servants, employees and/or against the instructor
or substitute teacher. I understand that any photography taken while participating in a class or related event may be used for
promotional purposes by BCA. In the event of emergency, I authorize BCA and the instructor to secure from any licensed
hospital, physician and/or medical personnel any treatment deemed necessary for my immediate care. I have carefully read,
fully understand and agree to the aforementioned. Further, to the best of my knowledge, the health information provided
above is accurate. Personal information will be kept secure and confidential.
I WILL NOT ATTEND FITNESS CLASSES WHEN ILL.
Signature: __________________________________________
Date: ____________________
BREAST CANCER ACTION
Fit & Fab WINTER Program
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Your registration is complete upon Breast Cancer Action receiving the waiver and your session choices. You can
mail/email or hand deliver it to Breast Cancer Action, 301-1390 Prince of Wales Dr., Ottawa, ON K2C 3N6 –
info@bcaott.ca. We do not accept fitness registration by phone.
NEW PARTICIPANTS MUST submit a waiver BEFORE starting any class.
Please indicate your 1st, 2nd and 3rd choices by an X. You must read our fitness guidelines fully and acknowledge below...
They can be accessed at http://bcaott.ca/what-we-do/fitness-classes and click on the link.
WE WILL CONFIRM YOUR CHOICES VIA EMAIL AFTER THE REGISTRATION PROCESS IS COMPLETE.
I have carefully read and accept the Guidelines for Fitness Registration _________ (initial)
*Classes are not held during March Break or on Statutory Holidays*
Class Description
Maximum
Participants
Lian’s Tai Chi Saturdays 12-1PM JAN 16 – MARCH 19
Room B, Greenboro CC, 363 Lorry Greenberg Dr. (no class 13 Feb)
20
Belly Dancing Fridays 12:00-1:00 PM JAN 15 – MARCH 11
Greenboro Community Centre, 363 Lorry Greenberg Dr.
10
LEVEL 1 Yoga Tuesdays 12:30-1:30 PM JAN 12 – MARCH 29
Beyond Yoga, #3-66 Hearst Way, Kanata
25
Yoga Wednesdays 6:00-7:00 PM
JAN 13 – MARCH 30
Maplesoft Center, 1500 Alta Vista Drive (no class March 2)
12
Yoga Fridays 11:30-12:30 PM
JAN 15 – MARCH 11
Beyond Yoga, #3-66 Hearst Way, Kanata
25
LEVEL 1 Stretch & Strength Mon. 10-11AM JAN 11–MARCH 21
St. Laurent Complex, 525 Cote St. (no class Oct 12)
15
Stretch & Strength Wed. 10-11 AM JAN 13 – MARCH 30
NEW TIME St. Laurent Complex, 525 Cote St.
15
Stretch & Strength Fridays 10:00-11:00AM JAN 15 -MARCH 11
St. Laurent Complex, 525 Cote St.
15
Stretch & Strength Wednesdays 2:30-3:30 JAN 13– MARCH 30
Goulbourn Recreation Complex, 1500 Shea Rd.
20
Stretch & Strength Tuesdays 10:30-11:30 JAN 12–MARCH 29
Nepean Creative Arts Centre, 35 Stafford Rd.
20
LEVEL 1 “Triple S” Thursday 11:30-12:30 JAN 14–MARCH 31
Maplesoft Centre, 1500 Alta Vista Drive (no class Oct 29)
10
Choice
1
Choice
2
Name: ___________________ Phone #: _____________ Year Diagnosed with Breast Cancer ________
Choice
3