Registration Form - HopOn.bike

Hop On Registration Form

PLEASE READ: Personal information will be treated in line with the General Data Protection Act of 2018. Information provided may be shared for the purposes of audit, research or put together with other surveys, but when we do this, your confidentiality is always maintained. Personal data will not be made public in any way which identifies individuals.

PLEASE NOTE: YOU WILL NEED TO COMPLETE A FORM FOR EACH PARTICIPANT

YOUR PERSONAL DETAILS

First Name

Last Name / Surname

Gender

Date of Birth - dd-mm-yyyy

Address Line 1

Address Line 2

City

Post Code

Mobile Number

Home Phone Number

Email Address

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Number

YOUR HEALTH

Do you have any of the following physical, sensory, learning, or mental health conditions, or illnesses that have lasted, or are expected to last, 12 months or more? (Please look at the list below)

IF YES PLEASE TICK ALL THAT APPLY TO YOUR CONDITION OR ILLNESS

Vision

Hearing

Mobility

Learning or concentrating or remembering

Mental Health

Stamina or Breathing Difficulty

Social or behavioural issues

Difficulty speaking / making yourself understood

Dexterity difficulties / problems using your hands

Other (Please specify)

If yes, do any of these physical, sensory, learning, or mental health conditions or illnesses have an effect on your ability to do normal daily activities?

*How is your health in general? Would you say it was:

* Current level of activity in a typical week

* Number of Days (per week) of at least 10 mins of physical activity

* Number of Days (per week) of at least 30 mins of physical activity

SOME MORE INFORMATION ABOUT YOU

Which one of the following best describes your ethnic group or background?

What is your religion, even if you are not currently practising?

Is English your first language?

What is your current working status?

Other (please specify)

YOUR CONSENT

I give my consent to emergency medical treatment should it be deemed necessary by a qualified medical practitioner.

I give my permission for any photographs taken during the session to be used as marketing material.

As part of the evaluation of Hop On, would you be willing to participate in a future survey?

I have been given an outline of the session and information relating to safety during the activities. I understand that whilst safety precautions are taken throughout the sessions sporting activities by their nature are not risk free.

I declare that the information in this form is correct to the best of my knowledge and that is any changes occur before or during activities, I will inform the organisers.

You must click the correct option to sign your agreement

If this is your registration. Sign here

Sign on behalf of the person you are registering

Your Full Signature Name