Please complete: All fields marked (*) are mandatory. I want to do ZUMBA I’ve done it before I’ve never done it before Invalid Input I want to do SWIMMING Beginner Intermediate Invalid Input I want to volunteer for Sports4Life Zumba Swimming Seminars Invalid Input Champions for Diabetes Awareness and Management I wish to attend Invalid Input Please supply your details below. Group bookings should be completed by the lead. Personal details First Name(*) Please type your full name. Last Name(*) Invalid Input E-mail(*) Invalid email address. Postcode(*) Invalid Input Mobile Number(*) Invalid Input Emergency Number(*) Invalid Input What age bracket are you in? My Age(*) 18-3435-5455+ Invalid Input Medical History Do you ever have pains in your chest? Chest Pains(*) YesNo Invalid Input Do you often feel faint or have spells of dizziness? Faintness or Dizziness?(*) YesNo Invalid Input Have you had any operations or injuries in the last year? Oporations or Injuries(*) YesNo Invalid Input Are you receiving medication for any condition? Receiving Medication(*) YesNo Invalid Input Do you have high blood pressure? Blood Pressure(*) YesNo Invalid Input Do you have a bone or joint problem, such as Arthritis, Osteoporosis, Back or Knee problems? (Circle all that apply) Bone Joint Problem(*) ArthritisOsteoporosisBack or Knee problemsNo issues Invalid Input Is there anything else we should know about your health? Anything Else(*) YesNo Invalid Input Please specify(*) Invalid Input If you have answered yes to any of the above please consult your GP prior to participating the class. Acknowledgement I acknowledge that by taking part in the class you acknowledge that you are exercising at your own risk and AT YOUR OWN PACE and are free to rest or break for water at any point you feel necessary. (please tick) By taking part in our exercise classes you acknowledge that you are exercising at your own risk and AT YOUR OWN PACE and are free to rest or break for water at any point you feel necessary.(*) I acknowledge the above Invalid Input Privacy: We will not share or pass on your data to any third parties. Your details are used for the S4LW Programme only. Captcha Code(*) Invalid Input Please add the above code in the box provided. Submit
