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FREEMOOVEMENT Registration form
Data collection for attendees.
* Required
Email address
*
Your email
Full Name
*
Your answer
Gender
*
Female
Male
Prefer not to say
Other:
Post code
*
Your answer
Group Name
*
Choose
Cowick Barton CB#1
Merrivale MV#2
Priory road PR#3
St.Thomas pleasure ground PG#4
Ludwell Valley LV#5
Belmont Park BP#6
Age
*
Under 18
18 - 29
30 - 39
40 - 49
50 - 59
60>
Do you consider yourself to have a disability? (e.g. a physical or mental impairment which has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities.)
*
Yes
No
Prefer not to say
If you consider yourself disabled/impaired, please describe if you are happy to.
Your answer
Please supply any medical information that the coach/leader should be aware of (e.g. recent illness, condition, injury or prescribed medication) which may affect your ability to join in with the full range of activities in the session and what support/modifications are needed). Please also make the leader aware at the start of the session.
Your answer
In the last 7 days.... what was the total number of minutes you spent doing a physical activity that raised your heart rate, made you sweat or made you out of breath? Please be honest as we really want to accurately understand how peoples active lifestyles may be changed as a result of attending our sessions.
*
0 - 30 MInutes
30 - 60 Minutes
60 - 90 Minutes
90 - 120 Minutes
120 - 150 Minutes
150> Minutes
PAR - Q (Physical activity readiness questionnaire) Only tick if you have conditions listed below.
My doctor has said I have heart trouble?
I frequently have pains in your heart and chest?
I often feel faint or have spells of severe dizziness
My doctor has said my blood pressure was too high
I have a bone or joint problem that could be made worse by a change in your physical activity?
I currently take medications that affect your ability to take part in physical activity?
I currently have a disability or a communicable disease?
None of the above
On the below scale how motivated are you to get active?
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Not at all motivated
1
2
3
4
5
6
7
8
9
10
Highly Motivated
What are your main reasons for joining a FREEMOOVEMENT session?
*
Improve fitness
Loose weight
Increase activity level
Train for an event
Meet new people
Other:
Required
Do you know of any reason why you cannot take part in physical activity?
*
Yes
No
Maybe
Required
Are you happy for us to use your data anonymously to help support our funding applications? We want to provide our funders with evidence of attendance and growth to keep FREEMOOOVEMENT going from strength to strength.
*
Yes
No
Are you happy for us to contact you with updates on groups and programme developments. We will never share this information with 3rd Parties.
Yes
No
Emergency contact details including: Name, contact number, relationship
*
Your answer
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