Workshop Registration - Access Care Partners

Which workshop would you like to register for?Class is full, but you can still put your name on the waiting list - A Matter of Balance - Managing Concerns About Falls - Fall 2026: Thursdays from September 3-October 22, 12:30-2:30pm in-person at the South Hadley Senior CenterBreaking Free from Chronic Pain - Empower Yourself with Self-Management Techniques - Wednesdays from September 16 - October 28 from 10:00 am - 12:30 pm virtually on Microsoft TeamsSavvy Caregiver - Fall 2026: Wednesdays, October 14-November 18, 1-3 pm at South Hadley Senior Center

Your First Name *

Your Last Name *

Physical Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Mailing Address (if different)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Email Address *

Phone *

Date of Birth *

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact's Relationship to You

Emergency Contact's Phone *

Are you a caregiver? *YesNo

Do you receive services from Access Care Partners?YesNo

How many people live in your household (under the same roof)? *

In order to report to our funders the average household income of our participants, please select the box that most closely describes your gross annual income?This information is requested for statistical purposes only to provide data to our funders. This information is requested but not required.

What is your most pressing health concern that motivated you to register for this class? *

What else do you think we should know about you in order to make this workshop a great learning experience for you?

Please tell us which senior center.

Which ACP Staff member sent the flyer?

Please tell us the name of the doctor's office.

Please tell us on which site.

Please tell us where in the community you saw the flyer.

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