All participants need to complete online form before they can start any classes. 

 

Please complete the form

Fullname

(Firstname and Lastname please)

Mobile Number

Emergency Contact Name

Emergency Contact Number

Has your GP advised you should only do physical activity recommended by a doctor?

Yes

No

Has your doctor ever said that you have a heart condition?

Yes

No

Do you feel pain in your chest when you do physical activity?

Yes

No

In the past month, have you had chest pain when you were not doing physical activity?

Yes

No

Do you lose your balance because of dizziness, or do you lose consciousness?

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity?i

Yes

No

Is your doctor currently prescribing drugs (for example water pills) for you blood pressure or heart condition?

Yes

No

Do you know of any other reason why you should not do physical activity?

Photo & Video Consent

(see below)

Yes

No

I give my consent for my image and/or video to be used by Mucklagh Community Centre for promotional, educational, and community purposes, including on its website, social media platforms, printed materials, and other publications.

I give my consent to be added to the MCC Active Link WhatsApp group.

(see below)

Yes

No

The MCC Active Link WhatsApp group is used to share information about this class, upcoming activities, and social lunches at Mucklagh Community Centre. If you would like to receive these updates, please tick the box above.

I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction.

Submit

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