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. 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.
MaleFemale
Date of Birth*

MonthDayYear
Date
Under 6060-6465-7071-7576-8081-8586-9091-9596+Choose not to answer
White/ CaucasianBlack or African AmericanNative Hawaiian or Pacific IslanderAsian or Asian AmericanAmerican Indian or Alaska Native2 or more racesChoose not to answerOther
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.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: