SAIL Exercise Class Registration Form

SAIL Exercise Class Registration Form
Stay Active and Independent for Life (SAIL)

Classes are held at the:

Loudoun County Area Agency on Aging

Administrative building- Program Room

742 Miller Drive, SE

Leesburg, VA 20175

Questions or need to explore transportation options: 571-439-9776 or email us at aaasupport@loudoun.gov

Classes are ongoing on Tuesdays and Thursdays from 2:30-3:30pm. Please join us anytime!
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender:
Date of Birth

MonthDayYear
Date
Age:
Race:

Other
Ethnicity:
Emergency Contact:

First NameLast Name
Emergency Contact Relation:
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Comments/Questions:
Please wear comfortable clothes for exercise, tennis shoes or sneakers, and bring a bottle of water. We have weights that you can use during the class.

SAIL is an evidence-based program to improve strength, increase balance, and prevent falls.
Should be Empty: