Body Balance (In-Person) 4-28-23

April 28, 2023

10:00 am – 11:00 am

Location: Daniel Boone Library – 300 Clarkson Rd, Ellisville, MO 63011

Presentation Description: Designed to help flexibility, strength, and activities for daily independent living.

Registration: Please REGISTER BELOW or call the Library at (314) 994-3300. Lunch donations are appreciated https://www.agingahead.org/donate/

CHOICE EVENT REGISTRATION FORM

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Name*

First Last

Email*

Phone*

Are you a CHOICE member?*

Yes, I am a CHOICE member.

No, I need to sign up for the free CHOICE program.

Check Yes, if you have already filled out our 10 questions like address, birthday, primary race, etc. Check No, if you need to answer these additional questions.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Birthdate (MM/DD/YYYY)*

Gender*

Ethnicity*

Primary Race*

Medicaid Eligible*

Rural*

Low Income*

Yes

Unknown

Use this chart to determine if you are low income - [1 in household: $1,040.83/month] [2 in household: $1,409.17/month] [3 in household: $1,777.50/month] [4 in household: $2,514.17/month]

Number in Household?*

Lunch Order

Lunch must be ordered 48 hours in advance, by Wednesday at 10:00am. (Please note the program has a 5 lunch order minimum and lunches may not be available.)

Box Lunch Options (No Substitutions)*

Side Salad or Entrée Salad Dressing*

Milk*

Name

This field is for validation purposes and should be left unchanged.

Body Balance (In-Person) 4-28-23

Lunch Order

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