Active Lifestyles – Individual Registration Form You can also apply online at www.manchester.gov.uk/activelifestyles Personal details Title:...............Surname:...............................................................................First name(s):............................................................................................... Address for correspondence (this is required for us to send you your membership card) Address:............................................................................................................................................................................................................................. ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� ......................................................................................................................Postcode:..................................................................................................... I am resident in the city of Manchester Date of birth: D D / M M / Y Y Yes Y No Y Gender: Male Female Ethnic origin Asian or Asian British – Bangladeshi Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British – Other Black or Black British – African Black or Black British – Caribbean Black or Black British – Other Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean Mixed – Other Mixed Background White British White Irish White – Other White Background Chinese Other Rather not say Yes No Rather not say Disability Do you consider yourself to have a disability? If yes, please give details:................................................................................................................................................................................................ ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� ������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 71197 2pp Registration Form.indd 1 21/10/2011 16:11 Contact details Home phone:...................................................... Work phone:......................................................... Mobile phone:...................................................... Email:��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� Emergency contact (this is required for your own safety) Name:�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� Phone number:����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� How did you first hear about this programme? Poster/flyer Friend Word of mouth Manchester City Council employee GP Newsletter Website Leisure centre Library PARS Newspaper Other/details:..................................................................................................................................................................................................................... About you We want to make sure our programmes help everyone become more active. We would like to know how active you are at the moment. On average, are you physically active: More than once a week Once a week Once a month Less than once a month Never If you ticked More than once a week, please circle the number of days on which you have done a total of 30 minutes or more of activity that was enough to make you breathe faster: 1234567 Activities should include sport, exercise, brisk walking or cycling, but should not include housework or physical activity that is part of your job. 71197 2pp Registration Form.indd 2 21/10/2011 16:11 Well Being We would like to know how you are currently feeling about yourself and if we are helping you to feel better. Below are some statements about feelings and thoughts. They are designed to give an indication of your general level of wellbeing. Please ensure that you answer all questions. Please tick the box that best describes your experience over the past two weeks. None of the time Rarely Some of the time Often All of the time I’ve been feeling optimistic about the future I’ve been feeling useful I’ve been feeling relaxed I’ve been feeling interested in other people I’ve had energy to spare I’ve been dealing with problems well I’ve been thinking clearly I’ve been feeling good about myself I’ve been feeling close to other people I’ve been feeling confident I’ve been able to make up my own mind about things I’ve been feeling loved I’ve been interested in new things I’ve been feeling cheerful Personal goals It would be useful for us to know what you hope to achieve by participating and whether you meet these goals. This form will be given back to you at intervals for you to record whether your goals have been met or not. Tick any of the following that apply: I want to: Tick here if this goal is for you Date goal set Tick here when you think this goal has been met Date goal met Have a healthier lifestyle Feel better about myself Get fitter Lose weight Have more energy 71197 2pp Registration Form.indd 3 21/10/2011 16:11 Are you fit to exercise? (you must sign this in order to participate in the programme) 4 I understand that if I have any medical conditions that may affect my ability to exercise or I am taking any kind of medication, then I should seek medical advice before joining the programme. 4 I agree to inform the instructors of any such medical conditions prior to exercising, and to bring any required medication with me when participating. 4 I understand that I participate at my own risk. Signature:.......................................................................... Print name:.....................................................................................Date:............................... Signature of parent, carer or guardian (this is required if you are under 16):............................................................................................................ What do I do next? You can hand this form into your your instructor, nearest participating leisure centre*, or you can post it to us at: Active Lifestyles Centre, Denmark Road, Hulme, Manchester M15 6FG. You can also register online at www.manchester.gov.uk/activelifestyles or by calling us on 0161 232 3100. What happens next? You will receive your membership card very shortly, but you can participate in any session as of now. For up-to-date timetables and information on all our sessions please visit www.manchester.gov.uk/active lifestyles Please note that there is a charge for Active Lifestyles sessions. We often have special offers and promotions – to get the latest pricing structure please visit our website or contact us at the Active Lifestyles Centre on 0161 232 3100. You will also receive an Active Lifestyles card, which must be produced when attending an Active Lifestyles session. Please note that we charge a replacement fee of £2 for lost cards. *For a list of participating centres, see our website. Data protection Your personal information will be held and used in accordance with the requirements of the Data Protection Act 1998. Under the Act, Manchester City Council is the data controller for personal information collected from you when you register for the Active Lifestyles programme, and will ensure that the Council and its data processors will securely process and store the information you provide. Details of our data processors can be provided on request. Your information will be used for the following purposes: • to send you by post your membership card and other essential information you need to know about the Active Lifestyles programme • to verify information provided by you to determine eligibility for programme discounts in order to protect public funds • to contact you from time to time to give us feedback on the programme via your preferred contact methods above • to produce anonymised aggregated statistics to assess the effectiveness of the programme and for equalities monitoring purposes. Your personal information will not be shared with external third parties without your consent or where consent is unnecessary, the law allows for this. If you consent to us doing this, please tick here: More information about how we collect and use information can be found on our website: www.manchester.gov.uk/info/200031/data_protection_and_freedom_of_information or by contacting the Council. Check out the latest Council ebulletin, which keeps you up to date with Manchester news, events and services. Sign up at www.manchester.gov.uk/ebulletins Follow us on Twitter and Facebook. Look us up as mancitycouncil 71197 2pp Registration Form.indd 4 21/10/2011 16:11
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