Exercise Group – Northern Hub Exercise Group – Registration of Interest 2023 We are seeking expressions of interest for an exercise group! Where? Northern Hub Brain Injury SA (57 Elizabeth Way, Elizabeth) What? Exercise! Fun, recreational, physical activity in a supportive group environment Who? Participants from the Northern Hub and their carers and family. The group will be supported by BISA Physio and AHA staff. When? The time and day depends on interest. Please fill out the form below to help us decide! Participant Name * Participant Name Participant First Name Participant First Name Participant Last Name Participant Last Name Participant Email * Participant Contact Number * Please tell us who is completing this form: * Participant (myself) Support person Who should we contact about this registration of interest? * Participant Support person Please provide support person contact details (phone and email): * What day/s and time/s are you able to attend? Please select day and then write times in the space under the day. * MondayMonday TuesdayTuesday WednesdayWednesday ThursdayThursday FridayFriday Do you currently need assistance when standing and/or balancing? * Yes (with equipment) Yes (with carer/support) No (independent, no equipment or support required) Can you please provide some more detail on the type of support you will need to participate: Do you currently need assistance when walking? * Yes (with equipment) Yes (with carer/support) No (independent, no equipment or support required) Can you please provide some more detail on the type of assistance you will need to participate: Are there any barriers you have to joining the exercise group? (for example, transportation, personal medical history like low blood pressure) Are you a current Brain Injury SA client? * Yes No What funding source will you use to access this group? * NDIS LSA Third Party Self-funded Other (please specify)Other (please specify) If you are human, leave this field blank. Submit Exercise Group Registration of Interest
