Essentrics "*" indicates required fields Step 1 of 3 33% AGREEMENT IS REQUIRED FOR PARTICIPATION * RequiredI have carefully read the Schmieding Center’s Release and Waiver of Liability Statement and understand it to be a release and waiver of all potential claims and causes of action for my injury or death or damage to my property that occurs while participating in programs offered by the UAMS Schmieding Center, either in-person or via technology, and it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act(s) or omission(s). I agree Enter requested information below. * Required First Last Email * Required Phone * RequiredResidence CountyBentonWashingtonMadisonBaxterBooneCarrollIzardMarionNewtonSearcyStoneotherGenderMaleFemaleOtherRaceAfrican-AmericanAmerican IndianAsian/Pacific IslanderCaucasianHispanicMiddle EasternOtherHow did you learn about this program?My Center on AgingFacebookWebsiteWord of MouthMy Healthcare Provider (e.g., doctor, nurse, etc.)Other Survey data is required by our funder to offer this program at no cost to participants. Only aggregate (group) data from this survey is reported.How often do you exercise at home? * Required All the time Often Sometimes Never SCSHE How often are you active? * Required All the time Often Sometimes Never SCSHE How often are you sad or blue? * Required All the time Often Sometimes Never SCSHE How often do you gather with family/friends? * Required All the time Often Sometimes Never SCSHE How often do you fall? * Required All the time Often Sometimes Never SCSHE TestimonialYour comments about this program. For example, why did you register, what has been beneficial, etc.
