Program Details Where did you hear about this program? Preferred Venue Mondays at 11:30am - 1:00pm from 11 October - 29 November 2021 Tuesdays at 12:00pm - 1:30pm from 12 October - 30 November 2021 Tuesdays at 6:00pm - 7:30pm from 19 October - 7 December 2021 Mondays at 11:30am - 1:00pm from 14 February - 4 April 2022 (Mandarin In-Language) Tuesdays at 10am -11:30am from 15 February - 5 April 2022 Armidale Baulkham Hills Bexley North Bomaderry Bowral Byron Bay Campbelltown Coffs Harbour Cooma Dubbo East Maitland Engadine Frenchs Forest Gosford Goulburn Kiama Leichhardt Lidcombe Lismore Liverpool Liverpool – Arabic/Vietnamese Macksville Marrickville North Ryde Orange Parkes Penrith/Nepean Port Stephens Queanbeyan Springwood Sydney CBD Sydney CBD - Chinese Tweed Heads Valentine Waratah Brisbane South Brisbane West Townsville Toowoomba Adelaide Fleurieu Peninsula Mt. Gambier Albany Balga Busselton Geraldton Kalamunda Mandurah Midvale Mount Lawley Riverton South Bunbury Success Wanneroo Warnbro View a map of available venues to find your nearest program location. Personal Details First Name Last Name Date of Birth Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Address * Country * AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong S.A.R., ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe Address Address 2 City/Suburb State - None -Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postcode Home Phone Work Phone Mobile Email * Preferred communication method * Email Text Message Phone Country of Birth * Are you Aboriginal? * Yes No Are you Torres Strait Islander? * Yes No Are you Aboriginal & Torres Strait Islander? * Yes No Preferred language * Do you need an interpreter? * Yes No Disability We are committed to meeting disability or other support needs to assist you to participate in the Encore program. Please tick any of the following boxes if applicable. You will be contacted for more information prior to the course. Hearing impairment Visual impairment Other Do you have / live with a disability? Please describe your disability? Do you have a carer who will also be attending the program? * Yes No Emergency contact First Name Last Name Relationship Please define how your are related to your emergency contact, ie, sister, brother, friend. Phone Agreement Consent Form * Please tick your consent to one of the following I would like to attend an In-person Encore Program I would like to attend an Online Encore Program Consent Form I wish to enrol in the YWCA Encore program facilitated by YWCA Australia. In doing so, I waive all and any claim, right or course of action against YWCA Australia, its officers and servants for any accident, or illness, which occurs during participation in the YWCA Encore program. I further authorise the said officers or servants of YWCA Australia to administer first aid and/or procure medical assistance, as they may determine necessary, in the event of any illness or accident that may occur whilst attending the YWCA Encore program, and agree to meet any expenses incurred therein. I acknowledge the terms of the attached Privacy Policy. Consent Form It is a prerequisite to participation in any Encore exercise program that all participants complete the YWCA Encore process which includes submitting a Medical Approval form signed by their medical practitioner before attempting the exercises in our videos and that they follow their doctor’s advice. It is also a condition of participation in the online Encore program that you assume responsibility for exercising within your limits and that you assume all risk or injury to your person or property. To the extent permitted by law, YWCA Australia and YWCA Encore disclaim any and all liability in connection with the exercises in our online program and any instruction and advice provided. Technique correction and guidance is limited due to the online nature of these virtual classes. Instructors might recommend you use household items including fixtures. This is only a recommendation and you should ensure items you choose to use are secure and suitable to withstand exercise requirements. You are responsible for the safety and suitability of the environment and space you choose to undertake these classes in. If at any time you feel you are excising beyond your current fitness abilities, or you feel discomfort, pain, dizziness, or nausea you should discontinue exercising immediately and seek professional medical advice. I acknowledge the terms of the attached Privacy Policy. Authorise Agreement * I consent