Whitney Wellness Workshop Registration

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

For more information about each of the workshops, please click on the following links:

Here is the separate link to register for the Diabetes Prevention Program:

Diabetes Prevention Program Registration

Fall Prevention Workshops and Physical Activity

Living Well With Diabetes, Wed, Jan 8-Feb 19, 1:00-3:30, ZoomHealth Coaches for Hypertension Control, Wed, Feb 5-Mar 26, choose start time below, In Person/ZoomLiving Well with Chronic Conditions, Wed, Jan 15-Feb 19, 6:30-9:00, Zoom

If participating via Zoom, please note: All participants must have audio and visual technology capabilities. This could be a laptop or tablet with a camera and microphone, or a smart phone. Details will be emailed to participants once they have registered/prior to the class start date. The Whitney Senior Center will contact participants to practice using Zoom and will support technology challenges prior to the workshop start date. Through a grant, Whitney Senior Center is able to loan out technology for you to participate in a workshop. Please contact the Wellness Coordinator at 320-650-3082 for more information.

Please fill out the following information to help with funding source requirements to let us know who is participating in our workshops.

MaleFemaleOther/Non-Conforming

The privacy of your health information is important to the Whitney Senior Center and is mandated by law. As a participant in Whitney Senior Center Wellness Workshops, both you and other participants may discuss medical information in the presence of other participants, family members, staff, and Lifestyle Coaches. By signing below, you are agreeing to and authorizing the discussion of your personal medical information in the workshop group setting. Your signature also means that you will respect the confidentiality of the other members of the group by not revealing medical or any other identifying information after the session is over. Your signature also means that you will not hold the City of Saint Cloud, Whitney Senior Center, nor any of the officers or employees of either responsible for any breach of confidentiality committed by other patients in the group.

Whitney Wellness Workshops Attendance/User Agreement, Release & Waiver of Liability

I understand and agree as follows:

1. I understand and agree that any personal information obtained during this wellness program will be held as private , and that no medical information will be released without my consent. I specifically consent to the release of all my medical information to any medical officer or health care provider in the event of a medical emergency.

2. I agree to take full responsibility for all of my health choices, including but not limited to the choice to participate in any program or workshop, and may seek medical advice from my physician to be cleared prior to beginning the program or workshop. I will not hold a wellness instructor, volunteer, class leader, or any wellness program grantor liable in any way should I become injured or suffer any damages while, or after, I participate in a wellness workshop.

3. IN CONSIDERATION OF THE ACCEPTANCE OF MY AGREEMENT, I, THE UNDERSIGNED, INTENDED TO BE LEGALLY BOUND FOR MYSELF, MY HEIRS, EXECUTORS, AND ADMINISTRATORS AND DO HEREBY RELEASE ANY AND ALL SPONSORS OF THIS WELLNESS PROGRAM AND ITS REPRESENTATIVES, SUCCESSORS, AND ASSIGNS, FROM ANY AND ALL LIABILITY ARISING FROM INJURIES, INCLUDING DEATH, THAT I MAY SUFFER AS A RESULT OF MY PARTICIPATION.

4. I HAVE CAREFULLY READ THIS AGREEMENT, RELEASE & WAIVER OF LIABILITY, AND I KNOW ITS CONTENTS. I HAVE VOLUNTARILY SIGNED AS MY OWN FREE ACT.

Please type your name as an electronic signature.

This program is funded in part by the Older Americans Act Grant through the Central MN Council on Aging and the Minnesota Department of Health and Human Services. To continue to offer the program in the community, we ask to you consider making a contribution if you are able.