Registration form
First name
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*
. This is a required field
Last name
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*
. This is a required field
Email address
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*
. This is a required field
Phone number
#
*
. This is a required field
We might need to send last minute info about a class
Show password
Password
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*
. This is a required field
Must be at least 12 characters and include upper and lower case letters, a number and a symbol.
Show password
Repeat password
#
*
. This is a required field
Please select a customer group
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Yoga
Unassigned
Pilates
Drawing
Weights
Choir
Chair Yoga
Creative Writing
Cardiac
Gym User
Multiple
Mencap User
Were you referred to the gym by a health professional or did you decide to contact us independently?
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*
. This is a required field
By referral
Independently
Please give the first line of your address
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*
. This is a required field
(optional) Second line of your address
#
Please give your postcode
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*
. This is a required field
In the event of an emergency, who should we contact?
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*
. This is a required field
Please provide a phone number and the name of the person
Gender
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*
. This is a required field
Female
Male
Prefer not to say
Please provide Date of Birth
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*
. This is a required field
Please provide your date of birth in the format DD/MM/YYYY
Ethnicity
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*
. This is a required field
Select option
1. White
2. Asian/British Asian
3. Black, Black British, Caribbean or African
4. Mixed/Multiple
5. Other
6. Prefer not to say
Do you have a disability?
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*
. This is a required field
This question concerns your own perception whether or not a disability has been officially recognised in any way
No
Yes
Have you been diagnosed with any of the following conditions>
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*
. This is a required field
Please tick the check boxes for the relevant conditions , if any.
None of the below
Heart disorder
High blood pressure
High cholesterol
Type 1 diabetes
Type 2 diabetes
Osteoarthritis
Rheumatoid Arthritis
Osteoporosis
Asthma/COPD
Depression/Anxiety
Stroke
Parkinsons
MS
ME/Chronic Fatigue
Motor Neurone Disease
Other Neurological Condition
Weight Management
Low Back Pain
Joint Problems
Poor Balance/Mobility
Cancer
Learning Disability
Visual Impairment
Please list any other relevant conditions
#
List conditions that could be relevant to the activity you plan to undertake (e.g. heart/lung problems, diabetes, blood pressure, depression/anxiety). Type N/A if there is nothing to say
You can enter a maximum of 2000 characters
/ 2000
/ 2000
Injury / Surgery?
#
Please list any injury or recent surgery that could be relevant to the activity you plan to undertake
You can enter a maximum of 2000 characters
/ 2000
/ 2000
Medication?
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Please list any recent medications that could be relevant to the activity you plan to undertake
You can enter a maximum of 2000 characters
/ 2000
/ 2000
What is the name of your GP surgery?
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*
. This is a required field
Please provide the name of the surgery - we do not need the address
What is the phone number for your GP surgery?
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*
. This is a required field
You can enter a maximum of 2000 characters
/ 2000
/ 2000
What would you like to gain/achieve from the activities you plan to undertake?
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Please mention the activity or activities in your response
Do you have any prior experience of the activity you plan to undertake?
#
Please mention the activity in your response
Please give consent for us to hold your personal information by ticking the box
#
*
. This is a required field
By checking this box you are giving us consent to hold this information. You can see our full privacy policy on the Cambrian Centre website at the link below or ask the Manager for a copy.
You also agree to enter into any exercise activity at your own risk. If any medical conditions or relevant medication changes, please inform the activity leader.
I agree
https://cambriancentre.org/about/policies/
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