October 2021 Virtual Tai Chi for Arthritis and Fall Prevention

Once you complete your registration, you will receive an email from Kirby Thierheimer with UTMB Health with Zoom invite information and a consent form. This email will be prior to participation in any workshop.

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* 1. Full name and phone number

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* 2. Email address

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* 3. Home address

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* 4. Emergency contact name and phone number

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* 5. What is your age?

18-24

25-34

35-44

45-54

55-64

65-74

75+

Prefer not to say

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* 6. Do you have any medical conditions which may affect your ability to learn or safely practice Tai Chi?

Yes

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* 7. If yes, or if you are unsure, you must have a doctor's clearance before participating.

Cleared by Physician (must have documentation to confirm)

Unable to participate at this time

Not Applicable

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* 8. Enter the physical address you will be at when you attend this virtual workshop.

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* 9. What is your LOCAL emergency services phone number? (EMS agency, fire, or police department) This information is needed in case of an emergency, as 911 will not work if I dial it from my location.

Please contact Kirby Thierheimer at krvanwin@utmb.edu with any questions or concerns.