Thank you for your interest in our Encore exercise and wellness program. To complete the enrolment process you will need to: Fill in the online Participant Enrolment Form below Have a Medical Approval form signed by one of your treating doctors, and Sign a Privacy form. Download our Privacy Statement. Please start your enrolment by completing the following form. Program Details Have you attended a Program before? * Yes No How many times have you attended a program before? * How long ago was the last time you attended a program? * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2012201320142015201620172018201920202021202220232024 Where did you hear about this program? * Program * NoneOnline Exercise Program Term 1Webinar: Relationships & Sexuality - Joanne Lovelock, Clinical Lead VIC & TAS, McGrath FoundationWebinar: Navigating other People's Reactions to your Diagnosis - Kerry Patford, Chief Clinical Leader, McGrath FoundationBowral Exercise ProgramFrench's Forest Exercise Program-Term 1Leichhardt Exercise ProgramNorth Ryde Exercise Program Term 1 2022Orange Exercise ProgramParkes Exercise ProgramSydney CBD Exercise Program - English & Mandarin SpeakingTweed Heads South Exercise ProgramWanneroo Exercise ProgramFleurieu Peninsula - Hayborough Exercise ProgramBrighton Exercise ProgramMount Gambier Exercise ProgramNoarlunga Exercise ProgramExercise Programs - Please contact Women’s Health Tasmania on 03 6231 3212Toowoomba Exercise Program - MorningOnline Exercise Program Term 3Online Exercise Program - ArabicNepean Exercise Program Term 1 2022Nedlands Exercise ProgramWarnbro Exercise ProgramSydney CBD Exercise ProgramLiverpool Exercise ProgramGosford Exercise ProgramLismore Exercise ProgramOnline Exercise Program - ChineseToowoomba Exercise Program - EveningNoarlunga Exercise ProgramQueanbeyan Exercise Program Brisbane West - Indooroopilly Exercise ProgramSpringwood Exercise Program Brisbane South - Carina Exercise ProgramKiama Exercise Program Mount Annan Exercise Program Brisbane North - Sandgate Exercise ProgramBayside / City of Kingston - to be rescheduled to May 2022Darwin - Palmerston Program Box Hill Exercise ProgramFrenchs Forest Exercise ProgramNorth Ryde Exercise Program Bomaderry Exercise ProgramHurstville Exercise ProgramBayside/Kingston Exercise ProgramToowoomba Toowoomba - EveningBrisbane South - Carina Brisbane North - Everton HillsBrisbane West - SpringfieldTownsville Gosford Exercise ProgramBusselton RivertonBalgaBrighton Exercise ProgramNoarlunga Exercise ProgramBallarat Exercise ProgramLiverpool Exercise Program - English & Vietnamese SpeakingNorth Ryde Exercise Program - English, Italian & Spanish SpeakingGoulburn Exercise ProgramKiama Exercise Program Macksville Exercise ProgramHunter Region Exercise ProgramsMt Gambier Exercise ProgramFleurieu Peninsula - Hayborough Exercise ProgramBrisbane North - Everton HillsBrisbane South - Carina Brisbane West - SpringfieldAlice SpringsSuccess Exercise Program Sydney CBD Exercise Program TownsvilleDarwinMildura Exercise ProgramMildura Exercise ProgramFleurieu Peninsula – Hayborough Exercise ProgramFleurieu Peninsula – Hayborough Exercise ProgramBrighton Exercise ProgramBrighton Exercise ProgramNoarlunga Exercise ProgramNoarlunga Exercise ProgramMt Gambier Exercise ProgramMt Gambier Exercise ProgramRiverton Exercise Program Geraldton Exercise ProgramAlbany Exercise ProgramWanneroo Exercise ProgramAngle Park Exercise ProgramParkes Exercise ProgramBox Hill Exercise Program 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 * 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 * English Afrikaans Arabic Cantonese Dinka Filipino/Tagalog Greek Hindi Indonesian Italian Kurdish Malayalam Mandarin Nepali Persian/Dari/Hazaraghi Punjabi Samoan Shona Sinhalese Spanish Swahili Tamil Vietnamese Prefer not to say Other [please specify] Preferred language Other [please specify] 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 No 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 * Confidential Health AssessmentDownload the YWCA Encore Privacy Statement. Name of GP * GP contact details * ConditionsDo you have, or have you had, any of the following? (tick as appropriate) Fainting/dizzy spells * Yes Controlled No Epilepsy * Yes Controlled No Heart condition * Yes Controlled No High blood pressure * Yes Controlled No Low blood pressure * Yes Controlled No Asthma * Yes Controlled No Anaemia * Yes Controlled No Breathlessness * Yes Controlled No Diabetes * Yes Controlled No Chest pains * Yes Controlled No High cholesterol * Yes Controlled No Arthritis or other joint or muscle problems * Yes Controlled No Hip or knee Yes Controlled No Swimming * Yes Controlled No Do you have trouble getting in and out of a pool? Allergies * Yes Controlled No Known allergies * Are you currently taking any medication? * Yes No List of Medications Medication*Reasons for taking* Medication * Reasons for taking * Other medical conditions Please list any other relevant medical conditions that could affect your participation in ENCORE’s exercise program? Please note the following if you have an open wound you are not permitted to enter the water but may participate in the information and land exercise sessions. If you are currently undergoing treatment you will need clearance from your treating specialist. Details of breast surgery Date of breast cancer surgery * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Additional breast surgery Have you had further breast surgery (i.e., breast reconstruction, other) Yes No Type of surgery Optional Date of additional breast cancer surgery Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Are you still undergoing treatment for your breast cancer? Chemotherapy * Yes No Radiotherapy * Yes No Hormone therapy * Yes No Diagnosed with Lymphoedema * Yes No Lymphoedema affected areas Which part/s of the body are affected by lymphoedema Other Information Please list other information relevant to your breast cancer surgery or treatment Communication Preferred communication method * Email Text Message Phone Subscribe to Newsletter I would like to receive Encore's Backstage Chatter Newsletter Yes 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