Register for a session - Active Cumbria

Your Name

Job Title: *

Name of Care Home *

Name of Care Group *

Date of Training Course

Your Work Email Address *

Mobile Contact Number

Date of Birth

Your T-Shirt Size

Emergency Contact Name

Emergency Contact Number

Your manager's name

Your manager's work e-mail address

Previous Work Experience or Relevant Experience to Exercise Leadership:

Current Conditions/Injuries:

Additional Support Needs:

Statement of Special Educational Needs or Diagnostic Report:

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

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 ever lose consciousness?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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