SAIL Exercise Class Registration Form

SAIL Exercise Class Registration Form
Classes are held at:

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 3-4 PM. 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.
Gender:

MaleFemale
DOB*

MonthDayYear
Date
Age:

Under 6060-6465-7071-7576-8081-8586-9091-9596+Choose not to answer
Race:

White/ CaucasianBlack or African AmericanNative Hawaiian or Pacific IslanderAsian or Asian AmericanAmerican Indian or Alaska Native2 or more racesChoose not to answerOther
Ethnicity:

Hispanic or LatinoNon Hispanic or LatinoChoose not to answer
Emergency Contact:

First NameLast Name
Emergency Contact Relation:
Emergency Contact Phone Number:
Please enter a valid phone number.
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: