Registration

🟡 This registration is ready for review. Assign it to yourself, then place this registrant on the waitlist because they cannot attend this specific workshop. Change the status to "On hold" while registrant is on the Waitlist.

🟡 This registration is ready for review. Assign it to yourself, then place this registrant on the waitlist because they do not have Aetna as their insurance provider. Change the status to "On hold" while registrant is on the Waitlist.

🟡 This registrant is on the waitlist. To remove them from the waitlist, change the status to "Ready" or "Cancel this registration if the registrant will never attend this particular workshop.

🟡 This registration is ready for review. Assign it to yourself. If the registrant has an associated caregiver, enroll the caregiver by selecting Associate caregiver.
When completed, update the status to "In progress" where pre-workshop activities can begin.

🟡 This registrant is assigned to a Take Charge of Your Health Workshop. When the 8-week follow-up has been collected, update the status to "Completed".

Attending with a Caregiver? If you need an accommodation to attend and you need your caregiver, please let us know.

How to Register: Complete the form below to secure your spot.

Associate with registrant

Details

Participant first name: Unanswered
Participant last name: Unanswered
Participant email: Unanswered
Participant phone number: Unanswered
Date of birth of person being referred: Unanswered
Address of person being referred: Unanswered
Subaddress of person being referred: Unanswered

Associate caregiver

Details

Caregiver first name: Unanswered
Caregiver last name: Unanswered
Caregiver phone number: Unanswered
Caregiver email address: Unanswered

Attendance

Can you commit to attending at least 4 of the 6 workshops in this series? One of these must be either the first or second session.

Select only one

Yes No

Sorry you cannot attend this session. Please provide your information and indicate a better time or location below.

Your Information

First name

Last name

Phone number

Email address is required to received automated notifications and reminders about your workshop.

By registering for our workshops, you are consenting to program representatives contacting you by email and phone. Would you also like to opt into text messages from program team representatives?

Select only one

Yes (Message and Data Rates May Apply) No

Preferred contact method

Select only one

Email Phone No preference

Date of birth

Address

Address 2

Do you have Aetna for your health insurance?

Select only one

Yes No Do not know AgeOptions will contact Aetna to verify if you are a member.

🚨 Thank you for your interest. Please complete this form and a representative will be in touch with you regarding next steps.

Registrant is caregiver for program participant?

Caregivers are not required to add Emergency contact information.

Yes No

Emergency contact information

Please provide an emergency contact in case we need to reach someone on your behalf.

Emergency contact name

Emergency contact phone

Caregiver Needs

Do you need a caregiver to attend with you as an accommodation?

Select only one

Yes No

Would you like to complete the registration for your caregiver now?

Select only one

Yes No

Is the Caregiver needed during the workshop?

Select only one

Yes The caregiver needs to be in the room during the workshop. No

🛑 Stop:

If you are a program manager or workshop leader registering a caregiver, and the answer is "No" to the above question Caregiver is needed during workshop. Associate the caregiver without registering them for the workshop.

Please have your caregiver call 708-853-5433 to register and mention they will be attending as your caregiver.

Caregiver Information (Only displayed if participant chose to register a caregiver)

If a caregiver or family member will attend with you, please provide their information below. Caregivers must register and actively participate in the workshop.

Caregiver First Name

Caregiver Last Name

Does the registrant give the workshop provider permission to contact the care giver?

Select only one

Yes No

Caregiver Phone Number

Caregiver Email Address

Would you like to opt your caregiver into text messages from program team representatives?

Select only one

Yes (Message and Data Rates May Apply) No

Regardless of your consent selection(s), your phone number may be used when necessary to support your care recipient or notify you of event changes or cancellations.

Caregiver preferred contact method

Select only one

Email Phone No preference

Stay in the Loop for Future Workshops

Is there another city that would be more convenient for you to attend the workshop?

What ZIP code area works best for your workshop attendance?

Please select your preferred time for the event

Select only one

AM PM

Thank you! You may complete your submission now.

🚨Note: This class is subject to cancellation if the minimum enrollment requirement is not reached. In the event that the workshop is cancelled, a representative will be in touch with you regarding next steps.

If you completed the full registration form and are eligible to attend the workshop, your workshop leader will contact you before the start date with additional details.

If you filled out the stay in the loop form, thank you for your interest. We’ll notify you when new workshops become available in your area.

If you have any questions in the meantime, we’re happy to help.

For questions, to cancel or to make changes to your registration, please contact us: Email: info@ilpathwaystohealth.org <OR> Phone: 708-853-5433

Pre-workshop activities

🚨 Participant prefers email as their contact method.

🚨 Participant prefers phone as their contact method.

🚨 Participant has no preferred contact method.

Workshop Attendance

Did registrant attend Class 0?

Use only when Class 0 has been determined

Yes No

Did registrant attend Session 1?

Select only one

Yes No

Did registrant attend Session 2?

Select only one

Yes No

Did registrant attend Session 3?

Select only one

Yes No

Did registrant attend Session 4?

Select only one

Yes No

Did registrant attend Session 5?

Select only one

Yes No

Did registrant attend Session 6?

Select only one

Yes No

Did registrant attend Session 7?

Select only one

Yes No

Total sessions attended Calculated

Unanswered

Details

Attendance: Session 1: Unanswered
Attendance: Session 2: Unanswered
Attendance: Session 3: Unanswered
Attendance: Session 4: Unanswered
Attendance: Session 5: Unanswered
Attendance: Session 6: Unanswered
Attendance: Session 7: Unanswered

Is completer Calculated

Unanswered

Details

Total sessions attended (AO): Unanswered

Surveys

By submitting this form, you agree to receive emails about this event, including enrollment updates, required forms, schedule changes, and reminders.

Colibri Goals

Attendance

Your Information

Emergency contact information

Caregiver Needs

🛑 Stop:

Caregiver Information (Only displayed if participant chose to register a caregiver)

Stay in the Loop for Future Workshops

Thank you! You may complete your submission now.

Pre-workshop activities

Workshop Attendance

Surveys