Vidant Wellness Center 2017 Aquatic Arthritis Program
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1 Program Enrollment Process CLASS NAME CLASS DAYS CLASS TIMES FACILITY LOCATION VWC MEMBER Arthritis M & W 11:00-12:00pm Arthritis T & Th 11:00-12:00pm (Therapy Pool) $14 / VMC Regional Rehab month Arthritis T & Th 5:30-6:30pm Center (Hospital Pool) Arthritis M, W, & F 7:45-8:45am Arthritis M, W, & F 10:00-11:00am Arthritis M, W, & F 12:00-1:00pm Arthritis M, W, & F 1:00-2:00pm (Therapy Pool) $22 / month NON- MEMBER $26 / month $32 / month Nutrition 1 st Wed. of 2:30-3:30pm Group every Month (Classroom A) *Program registration deadline due by the 25 th of the month prior to desired start. No Fee No Fee 1) Review Program Description (pg. 2-3) 2) Turn in Program Enrollment Forms Turn in the following forms within this packet to the Front Service Desk: o Program Application Form (pg. 4) o Rights & Obligations Waiver (pg. 5) o Participant Auto Draft Form (pg. 6) o Participant Self Report Form (pg. 7) 3) Program Assignment A member of the Aquatic Department Leadership Staff will contact you electronically, via to confirm registration information & provide assignment options. Based on availability, participant will be assigned to a class that most closely accommodates information provided on the Application Form. Once program enrollment is completed, participants will be added to a permanent class roster. 4) Monthly Program Fee Monthly program fees will be drafted on, or about, the 1 st of every month from the account information provided on Participant Auto Draft Form. Participants may choose to pay a credit on their Program Account to avoid having the account provided on the Auto Draft Form being drafted. 1
2 Program Description People living with Arthritis, Fibromyalgia, or other rheumatic diseases may benefit from warm water exercise in an effort to reduce the onset of inflammatory joint pain. Low impact exercises identified by the Arthritis Foundation, are designed specifically to maintain or increase mobility and improve quality of life. Physical Requirements Participants should have a diagnosed onset commensurate with the program focus. Participants must be capable of gaining access to the pool unassisted by staff, be independently mobile in the water (unregistered persons, facilitators, etc. are not allowed to accompany participants into the pool), & be able to process directions as instructed, requiring minimal individualized attention. Aquatic Exercise Classes These classes are held at the VMC Regional Rehabilitation Center (Hospital Pool), which is ideal for warm water programming & the that affords an abundance of amenities. Space is dedicated to this program during its scheduled time(s). Description VMC Regional Rehab Center Instructor / Client Ratio 16 Participants 20 Participants Pool Location VWC Therapy Pool VMC Regional Rehab Center (2610 Stantonsburg Rd.) (2100 Stantonsburg Rd.) Pool Size Pool utilized is 20 x 30 Pool utilized is ~ 35 x 75 Pool Depth 4 5 with a mild slope 3 5 ½ with a mild slope Water Temperature Ranges 88º 92º Ranges 90º 92º Air Temperature Ranges 75 º 80º Ranges 85 º 90º Parking Information Member Parking Lot VMC Rehab Visitor s Parking Lot (*Note VMC Employee parking rules) Group Nutrition Classes In addition to aquatic exercise classes, monthly nutrition education groups are offered to this program s clients (at no additional fee), which are taught by registered dieticians to better inform participants of healthy eating habits, food & drug interactions, etc. Although included, monthly registration is required. Description Class Schedule: Max Enrollment: Meeting Location: Class Set Up: 1 st Wed of every month, from 2:30-3:30pm 20 Participants / monthly class VWC Classroom A Lecture / Presentation Style 2
3 VMC Regional Rehab Center Directions from : 1. When leaving, take Wellness Dr. to stop light at Stantonsburg Rd. 2. Turn Left onto Stantonsburg Rd. 3. Drive approximately 0.7 miles (crossing over Arlington Blvd.) 4. Turn Left onto Hospital Loop Rd. 5. Bare Left, driving away from the Children s Hospital & Women s Center 6. Regional Rehabilitation Center will be on the Right, before pedestrian cross walk & bus stop 7. Visitor Parking is located on both sides of the road; Right side is near the Regional Rehabilitation Center Pool & Left side is near the Day Rehabilitation Center (Vidant Health employees should follow guidelines as specified by Parking Enforcement) 8. Follow sidewalk to the back pool entrance door; if locked, ring door bell & staff will assist you 3
4 Program Application Form (Submit one per participant) Participant Name: Date of Birth: / / Participant is a: VWC Member (#: ) Who is a: New Client Non-Member Returning Client Home Phone #: ( ) - Mobile Phone #: ( ) - (required): Emergency Contact: Phone #: ( ) - Which class(es) within this program are you interested in applying for (mark all that may be desirable)? MW 11:00-12:00pm () TTh 11:00-12:00pm () TTh 5:30-6:30pm (VMC Regional Rehab Center) MWF 7:45-8:45am () MWF 10:00-11:00am () MWF 12:00-1:00pm () MWF 1:00-2:00pm () I,, authorize that I have read & understand the program information provided, as well as reviewed the Rights & Obligations Waiver. I acknowledge that there are inherent risks associated with enrollment in any community based program, attendance is at the discretion of the participant, & cancellation policies apply regarding withdraws / refunds. Participant / Guardian Signature Date / / *To be completed by Aquatic Department Leadership Staff* Application Form Received: // Associated Account #: Participant Was Contacted: // Class Enrolled In: Participant Was Processed: // Effective Start Month: 4
5 Program Rights & Obligations Waiver (Submit one per participant) Participant Name: Registration Process New participant enrollment deadline is the 25 th of the month prior to desired start; after the registration period has passed, changes to enrollment status may not be able to be made. Once class enrollment is completed, it is considered ongoing until participant submits formal notification to withdraw from the program (see Transfer / Refund / Cancellation Policy below). Participants will be set up with a personal Program Account. Monthly Enrollment Fees Monthly program fees will be drafted on, or about, the 1 st of every month from the account information provided on Participant Auto Draft Form (every participant must complete this form). Participants may choose to pay a credit on their Program Account to avoid having the account provided on the Auto Draft Form being drafted. If fees are uncollectable after the final attempt, the participant will be notified to reconcile the balance before returning to that month s class; should the balance not be paid by the end of the specified month, the participant will be automatically canceled from this program. Class Attendance Class schedule is considered tentative & subject to change, if necessary. Class attendance is at the discretion of the participant; make up classes will not be scheduled for any that are missed. In the unlikely event that a scheduled session must be canceled by, as a result of unforeseen circumstances, the situation will be assessed, and if appropriate, a makeup session &/or refund will be provided as specified by the facility. Participants must be independently mobile in the pool; due to space limitations, unregistered persons, facilitators, etc. are not allowed to accompany participants into the pool. Transfer / Refund / Cancellation Policy Transfer / refund requests cannot be processed after the specified registration deadline has passed for a monthly class session. In the event that a participant wishes to discontinue enrollment, submission of the Program Cancellation Form must be submitted by the 5 th of the month prior to desired withdraw (i.e. January 1 st withdrawal requires Program Cancellation Form to be submitted by December 5 th ). Participant / Guardian Signature Date / / 5
6 Participant Auto Draft Form *All participants are required to complete this form* Participant Name: Mailing Address: City: State: Zip Code: Home Phone #: ( ) - Mobile Phone #: ( ) - (required): I,, authorize payment for my monthly Aquatic Program enrollment fees from the institution listed below, through use of Electronic Funds Transfer (EFT). This shall remain in effect until I formally withdraw from this program by submitting my Program Cancellation Form (due by the 5 th of the month prior to desired withdraw). Participant / Guardian Signature Date / / *Once processed, the lower portion of this form will be detached and shredded for privacy reasons. Please select an account to keep on file and provide requested information: Bank Draft Bank / Name on Account Account # Routing # Checking Account Savings Account Credit Card Name on Card Credit Card # Expiration Date Visa Card / Master Card / 6
7 Participant Self Report Form Name: _ Date of Birth: / / Current Age: yr Height: Current Weight: lbs. Today s Date: / / Medical History / Risk Factors (Check all that apply) Diabetes Gestational Diabetes Heart disease High Blood pressure High Cholesterol Stroke Gastric bypass Thyroid problems List ALL Medications: Over the counter medications, supplements, vitamins, herbs, etc.: Substance Use Cigarette or use tobacco use: None Regular Use Quitting or recently quit Alcohol use: None Regular Use Quitting or recently quit Drug use: None Amphetamines Barbiturates Typical Dietary Schedule Meals / day Snacks / day 1 None Times you eat out / pick up food not prepared at home? Rare 1-3 per week 4-6 per week 7+ per week How often do you skip meals? 1-2 per day 1-2 per week Rarely or almost never How many hours do you sleep each night? Physical Activity Habits Aerobic / Cardiovascular exercise: Never / Rare 1-2 times per week 3-4 times per week 5-7 times per week Weights / Strength training: Never / Rare 1-2 times per week 3-4 times per week 5-7 times per week Beverage Choices (Report all that apply) Beverages you drink regularly: Water Coffee Juice Whole Milk 2% Milk 1% Milk Skim Milk Regular Soda Diet soda Sweet tea Unsweet tea Alcohol Daily oz. Consumed: Chronic Pain Conditions (Report all that apply) Neck Pain Back Pain Spinal Stenosis Leg / Hip Pain Pinched Nerve Joint Pain Inflammatory Pain Degeneration Neuropathic Pain *Avg. Pain Level: (*0 = No Pain / 10 = Intolerable Pain) 7
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PLEASE ARRIVE TO THE CLINIC 30 MINUTES EARLY FOR YOUR APPOINTMENT
130 North Broadway Table Grove, IL 61482 Telephone: (309) 758-5070 Fax: (309) 758-5007 www.cmhospital.com Thank you for choosing Table Grove Community Medical Clinic for your Healthcare needs. We always
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18121 E Hampden Ave, Unit E Aurora, CO
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Valley View Retirement Community 4702 East Main Street Belleville, PA PH: (717) Fax: (717)
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Back in Motion Physical Therapy P.L.C. Patient Registration and Authorization Form Please Print
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Prince Family Dentistry
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Back in Motion Physical Therapy P.L.C. Patient Registration and Authorization Form Please Print
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Lawrenceville Neurology Center Patient Registration Form
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VALLEY ENT ASSOCIATES, P.C.
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PLEASE NOTE: This file must be saved to your desktop before and after completing!
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Patient Register. Name: Social Security # Birth date: Occupation: Employer:
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Agape Physical Therapy and Sports Rehabilitation. Patient Name: Birthdate Social Sec.
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PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
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Welcome to the Aker Kasten Eye Center!
ALAN B. AKER, MD ANN G. KASTEN AKER, MD JILL F. RODILA, MD VITO J. GUARIO, OD KELLI F. WOLPER, OD Welcome to the Aker Kasten Eye Center! On behalf of the doctors and staff, we would like to thank you for
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NAME AND PHONE NUMBER OF PHARMACY:
Emil W. Tetzner, D.M.D., M.S. Practice Limited to Periodontics *Please complete both sides AND MAIL BACK TO OUR OFFICE* Name Street City & State Zip Code Home Phone Business Phone Cell E-Mail Birth Date
Dear patient: We welcome you to our practice and ask that you kindly complete or correct all information on this form.
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Prairie Life Chiropractic 1224 S. Main Ave. Sioux Center, IA 51250
Patient Information Name Birth Date Guardian s Name (If applicable) Address City State Zip Home Phone ( ) Cell ( ) Email Sex: Age SS# Race: Ethnicity: Occupation Employer Employer City Employer Phone(
Lasting Impressions Dentistry Sabrina Habib Heppe DDS, PS (206)
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