TCA/FP Registration Form for Monthly Instructor Series Tai Chi for Arthritis and Fall Prevention Monthly Series Registration for Certified Instructors Tai Chi for Arthritis and Fall Prevention Monthly Series Registration for Certified Instructors Participant Name: * Address (street, city, zip): * Phone: * Email: * Emergency Contact Name and Phone: * Name of the Area Agency on Aging and/or Senior Center where you currently or will teach: * Tai Chi for Arthritis and Fall Prevention Certification Status - Please check all that apply: * I hold a current certification for TCA/FP Part I I hold an expired certification for TCA/FP Part I I plan to be a recertified/newly certified Part I instructor in the next 6 months I hold a current certification for TCA/FP Part II I hold an expired certification for TCA/FP Part II I plan to be a recertified/newly certified Part II instructor in the next 6 months Acknowledgement of Personal Responsibility & Waiver: I understand that there is an inherent risk in any exercise activities. I agree to abide by the rules set out by my instructor. In consideration for admission to this workshop series, I hereby: (a) accept full responsibility for and assume the risk of any injuries sustained because of my participation in this series for practice of tai chi; (b) release and hold harmless the High Country Area Agency on Aging, its respective employees and directors, the instructor(s) and all personnel in association with the series for any liabilities, injuries and expenses which may arise as a result of participation in this series, practice or lessons involving tai chi. I know of no medical reasons why I should not participate in this workshop series. I understand that if I do have any medical reasons to not participate in this class, it is my responsibility to obtain a clearance from my doctor prior to starting. Participant Signature: * By typing your name in this blank you agree to the waiver. Date: * Optional: Please list below any particular interests or skills related to teaching TCA/FP that you hope to learn and develop as part of participating in this skills builder series. Thank you. Interests or Skills: reCAPTCHA Submit If you are human, leave this field blank.