Exercise Signup 2019-2020

Individualized Exercise & Weight Training at UD

For People with Disabilities or Limited Ability
Provide one-on-one assistance to help 'keep them movin'.

FALL 2019 / SPRING 2020 SEMESTER

STARTS FEB. 24, 2020
SIGN-UP FORM
Participate in an individualized exercise and weight-training program using Nautilus and/or free weights for strength training and conditioning. One-on-one exercise assistance is provided with staff or student volunteers—designed especially for you. There is NO FEE for this Semester program.

Due to the popularity of the one-on-one staff/volunteer assistance, there may be a waiting list. Select 1 or 2 days weekly to exercise with assistance. The program runs from September - May. Select ALL times that you are available so we can pair you with an assistant. Once paired, your 2 exercise sessions will be at the same time each week.

When: Spring Semester - Starts FEB. 24, 2020
September - May each calendar year (indiviual exercise is scheduled by appointment with student volunteer)

Where:
University of Delaware, Bob Carpenter Sport Center (Little Bob)*
Outdoor Recreation Resource Center, Rm. 005
26 N. College Ave., Newark, DE 19713

*The center is at the back of the parking lot across from McDowell.
Join the Exercise Program? *

Yes No
First Name *
Last Name *

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Number *
E-mail *
Available Times

Select all available times. One hour sessions will be scheduled twice a week in your chosen time slot(s).
Exercise Sessions *

I am available 8am - 11am‎ I am available 11am - 2pm‎ I am available 2pm - 5pm I am available 5pm - 8pm‎
Optional Message
Optional Message
To better serve you, please check boxes that apply. This information will help us design future programs.
Condition *

Amputee‎ Brain Injury‎ Cancer Cerebellar Ataxia Cerebral Palsy‎ CIDP Fibromyalgia‎ Hearing Impaired‎ Metal Poisoning MS‎ Paraplegia‎ Parkinson’s‎ Quadriplegia‎ Rheumatoid Arthritis‎ Sarcoidosis Spinal Fusion Stroke‎ Visually Impaired‎
Gender *

Male‎ Female
Age *

18 - 19‎ 20 - 29‎ 30 - 39‎ 40 - 49 50 - 59‎ 60 - 69‎ 70 - 79‎ 80 - 89‎
Are you a Military Veteran? *

Yes No
Do you use any mobility aides? *

cane‎ walker‎ manual wheelchair‎ power wheelchair‎ no, I do not‎
Need assistance to park your car?

Please indicate if you need assistance parking your car. Parking is limited. Participants can drive and park in front of the CSB (Little Bob) entrance and a student will greet you and park your car. They will place a temporary UD Handicap Placard in your car and park in a designated parking space.
Do you need assistance parking your car? If "yes," enter make and color of car below. *

Yes, I do No, I do not
Make of Car?
Color of Car?
Permission Request

For the exercise program to run effectively and safely, we need to share your information on this form with the exercise program's student volunteers who will assist you.
Permission to share your information? *

Yes, you may share No, you may not share
Programs are currently free.

Donations are greatly appreciated!
By submitting this sign-up form, you elect to participate in this Yes U Can program and you agree to allow the Yes U Can Corp. to use photographs and/or video that may be taken of these sessions for marketing purposes, e.g. website, Facebook, brochures, etc.
Website: YESUCANUSA.ORG
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