Apna Mind, Apna Body – Virtual Session Intake Form

Please select which answer best describes you?

I am a person with Dementia
I am a caregiver for a person with Dementia

If you are a caregiver, please provide your name, contact number and email address.

Information of the individuals participating in the workshop: Please provide your name, contact number and email address. *

Have you or your loved ones been formally diagnosed with dementia? *

Yes
No

Do you see a healthcare provider for your dementia care? *

Yes
No

How are you and your loved ones affected by Dementia diagnosis? *

Age of the participant?

What's the participant’s gender?

Which virtual workshops are you interested in attending? You will need access to zoom and an electronic device. Sessions will be scheduled on a weekly basis and an invite will be emailed to the email address provided at the time of intake.

Seated Yoga every Monday from 11:15am-12:15 pm
Seated Bollywood Dance any Wednesday of the month from 11:15 am- 12:15 pm
Seated Cardio Chair Exercise Session any Friday of the month from 11:30 am - 12:30 pm
Seated Zumba session any Friday of the month from 1:00 pm-2:00 pm

Exercise Waiver

Before you begin any new exercise program — even those designed for seniors, such as this one — make sure you are cleared by your doctor to participate in physical activity before beginning the program. If you experience any abnormal symptoms, you should stop the program and contact your physician. Remember, any movement is good for you and it is important to go at your own pace. Remember to breathe in from your nose and out from your nose and mouth as we go through each exercise. Wear proper footwear and comfortable clothing that allows you to move freely. For these online exercises, choose a solid, stable chair with an armrest that does not have wheels. Participating in exercise activities included on the Indus Community Services and Apna Health website site is done entirely at your own risk.

Please sign below *

Signature - please use your mouse or touchscreen to draw your signature.

Do we have the consent for the above? *

Yes
No

Do you have the permission from your family physician to participate in the physical activities?

Yes
No

Session maybe recorded and photographed for media and promotional purposes Do we have your Media consent? *

Yes
No

Virtual Programming Confidentiality Agreement

I understand that, as an observer and participants I may see, hear, or be exposed to confidential
information about others, such as health information, and personal information and services received. I acknowledge that it is my responsibility to respect the privacy and confidentiality of this information. I will not access (audio record, video, etc.) use, or disclose any confidential
information I observe during the virtual session.

Please sign below *

Signature - please use your mouse or touchscreen to draw your signature.

Date *

Apna Mind, Apna Body – Virtual Session Intake Form

Get health and wellness information in your language

905-366-1010

APNA MIND, APNA BODY - VIRTUAL SESSION INTAKE FORM

Exercise Waiver

Once we have received your information we will contact you with the next step.

Should you have any questions feel free to email us at info@induscs.ca