Participant Form Participant Form Step 1 of 7 14% Details of ParticipantName* Alternative Name [AKA]Gender*MaleFemalePrefer Not to AnswerDate Of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeCurrent Address Street Address Address Line 2 City ZIP / Postal Code Details of Participantcontinued...Contact Number*Emergency Contact NumberEmail ReligionFirst LanguageSchool / College / EmploymentSmokes*YesNoDisability(please state) EthnicityWhite British Irish Other White Background Black Caribbean African Black British Other Black Background Mixed White & Black Caribbean White & Black African White & Asian White & Chinese Other Mixed Background Asian Indian Pakistani Bangladeshi Asian British Other Asian Background Chinese or other ethnic group Chinese Other Ethnic Group Traveller Prefer Not To Say Not known / Specified Asylum Seeker (Please specify Ethnicity) Current Well-beingOver the last 4 weeks have you been experiencing any of the following… sleepless nights or restlessness paranoid [think people are looking at you] hyperactivity in the day anxious or worrying all the time extreme forgetfulness not eating properly or being sick after eating feeling low & depressed hearing peculiar noises or seeing peculiar things cutting, engraving biting or pinching your skin always angry or crying thoughts of suicide or bad thoughts other worries not mentioned Give more details:Are you Registered with a GP? Yes No HousingWhat is your current housing situation… Hostel Bed & Breakfast Re-housed Supported Housing Scheme Family Rented Accommodation Friends Other Other Health ScreeningFor most people, physical activity does not pose a hazard. The questions below have been designed to identify the small number of people for whom it would be wise to have medical advice before starting a new exercise programme.1. Has your doctor ever said you have a heart condition?*YesNo5. Do you have a bone or joint condition that could be made worse through physical activity?*YesNo2. Do you feel pain in your chest when you do physical activity?*YesNo6. Have you been diagnosed by your doctor with any of the following medical conditions? High Blood Pressure Heart Disease Diabetes Asthma COPD (Emphysema and Chronic Bronchitis) 3. Do you ever lose balance because of dizziness or lose consciousness?*YesNo4. In the past month, have you had a pain in your chest when you were NOT doing physical activity?*YesNoI understand that if I have answered ‘Yes’ to one or more of the above questions I may be required to seek medical advice before starting a new physical activity programme. I agree to tell the activity instructor if there is any change in any of my medical conditions. Please advise the instructor of any other conditions you feel they might need to know of. Assumption of Risk and Informed ConsentI herby state that I have read, understood and answered honestly the questions above and that I am participating in the physical activity session at my own risk.ConsentAgreement to take part in training sessions, matches and other sporting activities organised by Start Again Project CIC.(a) No liability shall arise or occur against The Start Again Project (CIC) for any loss damage or theft of personal property belonging to an individual, whilst participating in any Start again activity.(b) No liability shall arise or occur against The Start Again Project (CIC) for any death or injury occurring whilst participating in any Start Again activity, except to the extent that such injury or death was the result of a negligent act or omission of Start again, that could have been reasonably avoided, and was foreseeable.SignedCommentsThis field is for validation purposes and should be left unchanged.
