Active Communities Team Registration & PAR-Q (Phase 5)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Physical Activity Readiness Questionnaire

Email *

Full Name *

Contact Number *

Date of Birth *

YYYY

How old are you? *

18-25

25-35

35-45

45-60

60+

Gender *

Female

Male

Other

Prefer not to say

Postcode *

Do you consider yourself to be physically active. If yes, what activities do you do?

How many minutes a week do you take part in physical activity? *

None

Up to 30 minutes

30 to 150 minutes

Over 150 minutes

Ethnic Origin: Please specify your ethnicity *

Asian / Asian British

White

Black African / Caribbean / Black British

Mixed / Multiple Ethnic groups

Other

Prefer not to say

Do you have any of the following health conditions? *

Neurological: Stroke or other

Degenerative Brain Disease: Alzheimer's, Dementia or other

Cardiovascular Disease: Heart conditions such as angina, abnormal pulse or other

Endocrine Disorders : Diabetes Type 1 or 2, PCOS, Thyroid or other

Respiratory Disease : COPD, Asthma, Cystic Fibrosis or other

Bone Disease: Osteoarthritis, Rheumatoid Arthritis. Cervical Spondylosis or other

Blood Disease : Anemia, Thalassemia or other

Mental Health: Depression, Anxiety, OCD or other

Dizzy Spells

High or Low Blood Pressure

None

Other:

Required

If you have any of the conditions above please consult your doctor and confirm that it is safe for you to exercise. *

I understand and can confirm that I am fit and able to participate in the Active Community Team sessions

Required

Emergency Contact Number and Name *

We provide various outdoor, indoor and online (zoom activities) throughout the campaign. Our teams cater for different needs. Which team would you prefer? *

Active For All (Long term illnesses)

Forever Young (Over 60's)

Girl Power (Women Only 18-60)

Happy Families (Families)

Men Active (Men Only 18-60)

Not Sure - help me decide

Are you happy for a team member to contact you for further details and provide information about us? *

Yes

Other:

How did you hear about us? *

ACT Organiser (What is their name?) ........................................................................

Friends / Family

Social Media

Leaflets

NHS Services

Other:

Your Data - The purpose of us asking for this data is primarily for your safety and the monitoring of equal opportunities. This information will be stored only by the organisers working within the campaign and will only be stored for the duration of the campaign.

I understand and agree that I am happy for my data to be shared and reviewed within this campaign.

Clear selection

Photo consent - I hereby grant permission to Active Communities Team (ACT) full and free use of photographs and videos containing my image. I understand these images may be used for promotional, news, research and/or educational purposes on the internet or printed publications. *

Yes

No (If you prefer not to have your photo taken please let the photographer know)

Thank you for filling in this introductory Par-Q form. You will receive an email with our current timetables and a zoom link for online activities. Kindly ensure that you have your full name displayed on your screen for access to our online activities. If you do not receive a link please check your email junk box. We will be in touch to assist on your journey of well-being and to discuss further steps. In the meanwhile, if you have any queries or for further information please email us on: activity@accteams.uk.

Clear form

Never submit passwords through Google Forms.

This form was created inside of Southall Active Communities Campaign. Report Abuse

Forms