Physical Activity Provider Registration

Reject Reason:

All fields marked with are required.

Login Information

Username:

User ID must have minimum 6 characters in combination of alpha and numeric.

Password: Re-type Password:

The password is case sensitive and must be: minimum 8 characters in length - NOT containing any spaces

Registrant

Date of submission

Physical Activity Provider Organization name

Address

Address Line 2

City

Province

Postal Code/Zip Code

Primary Contact Name

Primary Email Address

Re-type Email Address

Primary Phone:
- -

Facility Website

Facility Email

Facility Phone Number
- -

Describe the goals and objectives (i.e. vision, mission, etc.) or approach to wellness of your organization. This will be publicly displayed

Why is your facility/Program interested in joining the Exercise is Medicine Aurora?

Select the types of facilities you have available. This will be publicly displayed

Spa	Basketball Courts
Swimming Pool	Weight Room
Other

Other Facilities

Are the services your facility provides suitable for patients who are new to being physically active?

Yes

No

Do you offer programs for children/youth?

Yes

No

Select the services you offer. This will be publicly displayed

Personal Training	Nutrition Counselling
Massage Sessions	Cardio Classes
Spin Classes	Aerobics Classes
Weight Training	Other

Other Services

As an Exercise is Medicine Service Provider, will your Organization commit to a one year membership with Activate Aurora?

Yes

No

Will your Organization provide a site tour to Exercise is Medicine staff as a condition of approval?

Yes

No

Will your Organization commit to mandatory semi-annual reporting requirements such as number of people referred and attendances?

Yes

No

Will your Organization offer 30 days free access to patients?

Yes

No

If not, please provide rationale and description of an alternate offer

Confirm that your facility will provide referred patients with (check all that applied):

A guided facility tour and introduction to equipment/ amenities.

Consultation about your facility services that meet the individual's needs and interests, and how goals might be met.

Access to trained/ certified staff.

List all current certifications of your professional staff: (eg. CSEP, ACSM, Canfitpro)

If your Facility Canadian Society of Exercise Physiology (CSEP) Accredited?

Yes

No

Attach any promotional material that will help describe your Facility to a potential user. If you have a picture of your logo, please also include the image here. This will be publicly displayed

Mission Statement: The Mission of Sport Aurora is to promote participation in sport and recreation for all citizens of the community we serve. Vision Statement: Sport Aurora is committed to be a progressive, dynamic leadership team promoting quality sport and recreation. Our Beliefs: Working together for the common good of sport. Providing sport opportunities for all. Demonstrating honesty, integrity and respect in our roles as community leaders in sport. Promoting the benefits of sport participation for all. Ensuring a safe, healthy, friendly and fun environment for all in sport Respecting all participants equally from the playground to the podium Encouraging fair play and adhering to the spirit of the rules Providing strong leadership support for our local sport organizations Recognizing the importance of volunteers’ contribution to sport Celebrating participation successes and expertise Working in partnerships and sharing resources and expertise both internally and externally. Recruiting, developing, retaining and recognizing competent, ethical and certified coaches and officials. A Member of VICommunity www.vicommunity.com, Powered by QC Technologies Inc., www.qcti.net