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FREEMOOVEMENT Registration form
Data collection for attendees.
Prefer not to say
Cowick Barton CB#1
Priory road PR#3
St.Thomas pleasure ground PG#4
Belmont Park BP#6
West Garth WG#8
Exwick (KINNERTON WAY) KW #9
Devon CC DC#10
18 - 29
30 - 39
40 - 49
50 - 59
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.)
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.
0 - 30 MInutes
30 - 60 Minutes
60 - 90 Minutes
90 - 120 Minutes
120 - 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?
Not at all motivated
What are your main reasons for joining a FREEMOOVEMENT session?
Increase activity level
Train for an event
Meet new people
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
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