.lightbox .lb-cancel{--wpr-bg-6b73757a-3cdd-418a-88b5-7232b4a4300b: url('https://www.indianaparkinson.org/wp-content/plugins/wp-embed-facebook/templates/lightbox/images/loading.gif');}.lightbox .lb-nav a.lb-prev{--wpr-bg-385ca85b-04da-4f07-9ab2-e4580761f0e5: url('https://www.indianaparkinson.org/wp-content/plugins/wp-embed-facebook/templates/lightbox/images/prev.png');}.lightbox .lb-nav a.lb-next{--wpr-bg-f6c2ad31-6c1d-4a92-879b-3fddeea4749e: url('https://www.indianaparkinson.org/wp-content/plugins/wp-embed-facebook/templates/lightbox/images/next.png');}.lightbox .lb-data .lb-close{--wpr-bg-60d47dc3-82e0-4d37-9ac6-8b6444dff554: url('https://www.indianaparkinson.org/wp-content/plugins/wp-embed-facebook/templates/lightbox/images/close.png');}.mmt_container .reveal-modal{--wpr-bg-bce3e554-9aea-4589-abeb-5f7a759199af: url('https://www.indianaparkinson.org/wp-content/plugins/meet-my-team/public/css/modal-gloss.png');}#footer{--wpr-bg-0841754c-6089-4b9b-87b7-e76cfd22baa9: url('https://www.indianaparkinson.org/wp-content/themes/indianaparkinson/images/footer-bg.jpg');}.social li a{--wpr-bg-17c3317b-762a-411e-b0e1-f61ed938259a: url('https://www.indianaparkinson.org/wp-content/themes/indianaparkinson/images/sprite.png');}#footer .form .head:before{--wpr-bg-6c20ce12-0448-4f27-b490-a247bd3548be: url('https://www.indianaparkinson.org/wp-content/themes/indianaparkinson/images/sprite.png');}.left .widget{--wpr-bg-98993b6e-778e-4a93-9971-fdc09d857e68: url('https://www.indianaparkinson.org/wp-content/themes/indianaparkinson/images/card-bg.jpg');}.gform_legacy_markup_wrapper .gform_card_icon_container div.gform_card_icon.gform_card_icon_selected:after{--wpr-bg-5fb30613-cac2-45a0-9ccb-5e08515c9d67: url('https://www.indianaparkinson.org/wp-content/plugins/gravityforms/images/gf-creditcards-check.svg');}#rmp-container-4980{--wpr-bg-4a42d17e-bd8b-4133-b7f0-75d3554cd53b: url('https://www.indianaparkinson.org/');}.lightbox .lb-nav a{--wpr-bg-cd9f945c-442a-4708-a57e-41ff3af0b8cf: url('https://www.indianaparkinson.org/data:image/gifbase64,R0lGODlhAQABAPAAAP///wAAACH5BAEAAAAALAAAAAABAAEAAAICRAEAOw==');}.gform-legacy-datepicker.ui-datepicker .ui-datepicker-next,.gform-legacy-datepicker.ui-datepicker .ui-datepicker-prev{--wpr-bg-a7cf293d-808f-4f79-a4b4-5e83c8748b47: url('https://www.indianaparkinson.org/wp-content/plugins/gravityforms/legacy/images/datepicker/arrow.png');}.gform_legacy_markup_wrapper .gform_card_icon_container div.gform_card_icon{--wpr-bg-70356170-102c-419a-889e-9fb8ddc1c986: url('https://www.indianaparkinson.org/wp-content/plugins/gravityforms/images/gf-creditcards.svg');}

Thank you for purchasing an iCLIMB Membership.

Before you get started, we need a bit of information about you. Please fill out the Participation Form below:

iClimb Registration

Personal Information
First Name*
Middle Initial
Last Name*
Date of Birth*
MM slash DD slash YYYY
Address*
Home Address 1 Home Address 2 City State Zip
Phone Number*
Email*
Caregiver/Spouse Information
First Name*
Middle Initial
Last Name*
Is the address same as above?*
- Same address
Address*
Home Address 1 Home Address 2 City State Zip
Phone Number*
Email*
Relationship to exercise participant*
Emergency Contact
Is your emergency contact the same as your Caregiver/Spouse?
- Same contact
First Name*
Last Name*
Relationship*
Phone Number*
What are your goals for this exercise class?*
How did you hear about the CLIMB?*
Permission to use photograph*
- I grant the Indiana Parkinson Foundation, its representatives and employees the right to take photographs of me and my property with the above-identified subjects.
*
- I authorize the Indiana Parkinson Foundation, it’s assigns and transferees to copyright, use to publish the same in print and or electronically.
*
- I agree that the Indiana Parkinson Foundation may us such photographs of me with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising and web content.
Signature box*
Printed Name*
Date*
MM slash DD slash YYYY

Top