Contact Registration Form

Fill out the form below to register your Physical Activity Falls Prevention Program. If you have more programs to register, please follow the instructions.

Step 1: Registration of Physical Activity PROVIDER via the Contact Registration Form

Step 2: Registration of the Physical Activity Falls Prevention PROGRAM via the Program Registration Form

(details provided in this "personal contact details" section are confidential and will not be included in the web-based directory. Please provide these details so we can contact you if necessary.)

Step 1 - Personal Details

Title:*

First Name:*

Last Name:*

Company Position:

Email:*

Confirm Email:*

Once your registration has been accepted, this password will allow you to log in and edit your and your program's details. Paper-based update forms will be provided if you prefer. Please indicate your preferred password (please include at least one number in your password):

Password:*

Confirm Password:*

Phone:

Phone (Mobile):

Address Details

Address:*

Town/City:*

Postcode:*

Select your Area Health Service:*Greater SouthernGreater WesternHunter/New EnglandNorth CoastNorthern Sydney/Central CoastSouth Eastern Sydney/IllawarraSydney South WestSydney West

Not sure which AHS to select? Find your Area Health Service

Country:*

State:*

To register your programs, proceed through to Step 2 by clicking 'Continue'.

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How to Stay Active & Healthy

Did you know?

When in public places, you should pay particular attention to your surroundings including unsafe surfaces, obstacles, animals, children or cyclists. Scan the area before walking.