Feel Good for Life Bridgend - Registration Form

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Supporting people affected by dementia, loneliness and depression, and carers, to be physically active and reduce feelings of social isolation within Bridgend County Borough.

Feel Good for Life runs weekly in several locations:

Mondays at Ogmore Valley Life Centre from 2:15pm to 4pm

Wednesdays at Bridgend Life Centre from 2pm to 4pm

Fridays at North Cornelly Community Centre from 1:30pm to 3pm

Each session includes low-impact exercise and the opportunity to socialise and participate in different activities, such as quizzes, puzzles, scrapbooking, singing, seminars and information sessions. Everything is optional, so you can participate in whatever way you feel comfortable.

Free community transport is available.

Please fill in sections relevant to you.

Questions with a red asterisk are required.

I understand why I am being asked about taking part in the Feel Good for Life Programme and what will happen next.

I know that my name won’t be used.

I know I can ask questions about this.

I know that if I become uncomfortable, or don’t want to keep going I can stop.

I know that any health details that I provide will be used to make sure activities provided are appropriate for me.

I agree to the Feel Good for Life programme contacting me from time to time with information or questionnaires about the programme.

I have not been informed by any health care professional that I have any medical conditions that might interfere with me exercising safely within my own physical capabilities.

I agree to participate in any promotional photographs/ images for Halo Leisure

Yes

Which Feel Good for Life session(s) will you be attending? (Choose all that are applicable)
*

Swimming at Bridgend Life Centre

Activities at Ogmore Valley Life Centre

Activities in North Cornelly

Required

How did you hear about this program? (Choose all that are applicable) *

BAVO/Community Navigator

Alzheimer's Society

Awen

Bridgend County Borough Council

Bridgend Carers Centre

Tu Vida

Word of Mouth (friend, family member, etc.)

Other

Other:

Required

Name of Participant *

Address

Postcode *

Phone Number *

Date of Birth *

YYYY

Has a GP diagnosed you with dementia? *

Yes

If yes, what type of dementia were you diagnosed with?

Approximately when were you diagnosed with dementia?

YYYY

Any Other Disability (Choose all that are applicable)

Hearing Impairment

Learning Disability

Long standing illness or health condition

Mental Health condition

Physical Impairment

Vision Impairment

No Disability

Any other medical conditions / medications?

Will you attend sessions *

Alone

With a friend/family member who would like to participate

With a carer who would like to participate

With a friend/family member who would not like to participate

With a carer who would not like to participate

On a scale of 1-5, with 1 being very low and 5 being very high, how would you rate the following:

Your physical health?

Clear selection

Your mental health and wellbeing?

Clear selection

Your confidence to enter a leisure centre or community centre and participate in activities?

Clear selection

Your level of connection to others in your community (ex- friends, neighbours, family members, etc.)?

Clear selection

Your connection to support services and activities in your area (ex- support groups, activity groups)?

Clear selection

Over the previous week, how many times were you active for 30 minutes or more? e.g. walking, manual work, dancing, taking part in sport or leisure activity?

None

1-2 Times

2-3 Time

3-4 Times

5 Times or More

Clear selection

Is there anything else you would like us to know?

Clear form

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