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MSA Registration Form
Please take a couple of minutes to complete this form. All data is confidential and will not be shared with anyone.
Email address *
First Name *
Your answer
Surname *
Your answer
Age *
Required
Occupation *
Your answer
Religion *
Full Address Including Post Code *
Your answer
Mobile Phone number *
Your answer
Emergency Contact Details (Name and Contact Number) *
Your answer
Ethnic Background *
MSA Session attending *
Your answer
Do you consider yourself to have a disability *
Required
Do you consider you to be inactive (less than 30mins a week) *
Medical Needs/Allergy/Conditions *
Your answer
Physical Activity Rediness Questionnaire (PAR-Q) *
Yes
No
Has Your GP ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical actvity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity
Is your GP currently prescribing any medication for blood pressure or a heart condition?
Do you know of any reason why you should NOT engage in physical activity
Have you discussed any injuries with the instructor/coach before you start the activity.
Which MSA activities do you attend? *
Required
How did you hear about MSA *
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