--- title: Sign Up | Moving Together Classes --- ## Welcome! We are so excited for you to join a Moving Together® class! Completing this form is the next step on the path. Want to learn more about Moving Together? Visit our [Program Information](https://www.togetherseniorhealth.com/for-participants) page. Still have questions? [Contact Us](https://www.togetherseniorhealth.com/for-participants#contact-us-form) and let us know your situation and/or additional questions. **Please review** before signing up for Moving Together classes: Health Guidelines Tech Requirements Payment Information ### Let's get started After you submit this form, we'll call the primary contact phone number and review class start dates, times, and next steps. Your email address We will email you regarding this Moving Together sign up request. Please enter a valid email address ## Class Finder Questions What is your relationship to the primary participant? If you are signing up solo, choose "Self". Self As a class partner As a care partner not attending class As a family member not attending class As a friend not attending class As a case manager Other Please select your relationship Primary Participant First Name Please enter first name Primary Participant Last Name Please enter last name Primary Participant Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Primary Contact Phone Number Please enter a valid phone number "I agree to receive relevant text messages or reminders at the phone number provided above. Consent is not a condition to participate in classes. Message & data rates may apply. Reply HELP for help and STOP to cancel. View our Terms of Service and Privacy Policy." I agree to receive text messages at the phone number provided above. Yes No Please select an option Primary Contact First Name If the primary contact is NOT attending classes Primary Contact Last Name If the primary contact is NOT attending classes Participant Email Address If different than previous screen ## Primary Participant Mailing Address This is the location where the participant(s) will attend the online Moving Together class from the majority of the time. This is used to send them class supplies in the first weeks of class. **Note:** Moving Together classes are currently offered to US residents only. Street Address Please enter street address Address Line 2 City Please enter city name State Select a state... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please select a state Zip Code Please enter zip code Country ## Class Partner Information No partner? Skip → **Note:** A family member, friend, or care partner is welcome to join the primary participant for classes as a Class Partner. A class partner is recommended for those attending the Seated or Active classes and optional for those attending the Balance and Coordination and Proactive Brain Health classes. There is no additional charge for a class partner to attend. Class Partner First Name Class Partner Last Name Class Partner Relationship to Participant Select relationship... Spouse/Partner Care Partner Family member Friend Case Manager Other Class Partner Email Class Partner Primary Phone Number "I agree to receive relevant text messages or reminders at the phone number provided above. Consent is not a condition to participate in classes. Message & data rates may apply. Reply HELP for help and STOP to cancel. View our Terms of Service and Privacy Policy." I agree to receive text messages at the phone number provided above. Yes No ## Questions For Class Participant(s) The required questions will help us determine the class that best suits the class participant(s). Which option best matches the class participant's current level of mobility? (Please choose the answer for the participant with more mobility challenges.) I can walk comfortably and confidently on my own for 15 minutes or more. I am concerned about my balance and falling. I have trouble walking and/or have fallen in the past 3 months. I cannot sit in a chair for an hour comfortably or I cannot move out of bed. Please select a mobility option Which option best matches how the class participant(s) thinks and remembers? (Please choose the answer that best matches the participant with the most cognitive challenges.) I sometimes misplace things but can usually figure it out. I have some trouble saying what I'm thinking or finding the right words. I often feel confused, anxious, forget things or have trouble focusing. I struggle to follow conversations and cannot join group activities. Please select a cognitive option What best matches the class participant's comfort using the internet for things like sending emails and joining Zoom meetings on their own? Yes, I can email and join Zoom on my own. No, but I have someone who helps me with those regularly. No, I need help with those. I prefer not to answer. Please select an option How did you learn about the Moving Together® program? (Choose one) Doctor or other Health Care Provider Clinic Family member Friend Social Media Current MT Student Case Manager Other Please select an option What is your time zone? Eastern Time (ET) Central Time (CT) Mountain Time (MT) Arizona (MST - no DST) Pacific Time (PT) Alaska Time (AKT) Hawaii Time (HST) Please select your time zone Which days/times work best for the class participant(s) in your time zone? Choose all the days and times that work best for you. I am wide open and can make most class dates and times work Monday and Wednesday mornings Monday and Wednesday afternoons Monday and Wednesday evenings Tuesday and Thursday mornings Tuesday and Thursday afternoons Tuesday and Thursday evenings Other, I can explain more when we talk Please select at least one option What, if any, assistive devices does the class participant(s) use regularly? Select as many as apply to the participant and/or the class partner. Glasses/Contact Lens Hearing aids Cane Walker Wheelchair Oxygen Dentures/Dental devices None of the above Other Please select at least one option What would you like your Moving Together instructor to know to support you in class? For example: Why are you interested in the Moving Together program/classes? ## Sign Up Complete! Thank you for signing up for Moving Together® classes. We will contact you soon to provide information on class start dates, times, and next steps. Step 1 of 5 Previous Next × ### Form Data Debug × ``` {} ``` Press / to toggle Fill Page Fill All Fill & Submit Copy JSON