Full Name *

Gender *

Post code *

Group Name *

Age *

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.) *

Employment status. *

If you consider yourself disabled/impaired, please describe if you are happy to.

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.

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. *

PAR - Q (Physical activity readiness questionnaire) Only tick if you have conditions listed below.

On the below scale how motivated are you to get active? *

What are your main reasons for joining a FREEMOOVEMENT session? *

Do you know of any reason why you cannot take part in physical activity? *

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. *

Are you happy for us to contact you with updates on groups and programme developments. We will never share this information with 3rd Parties.

Emergency contact details including: Name, contact number, relationship *