Participant Information:
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
Town/City
State / Province
Postcode
E-mail Address
*
Confirmation Email
example@example.com
Telephone Number
*
Emergency Contact
*
First Name
Telephone
MEDICAL CONDITION
This information is required to help us tailor physical activity programmes to your individual needs
Cancer Type
*
Date of Diagnosis
*
Treatment:
*
Please provide an overview of your treatment to date and/or any treatment has been planned
Other medical condition(s):
Please provide details in relation to any other medical condition(s) that you currently have, or have had in the past
REFERRAL INFORMATION
How did you hear about this service?
*
Did you receive a referral to this service from a healthcare professional?
*
Yes
No
Please provide contact details for the healthcare professional that referred you to this service
Name
First Name
Last Name
Position / Job Title
Email Address
example@example.com
Telephone Number
Please enter a valid phone number.
NOTES & INFORMATION
CONSENT
I consent to the following:
(1) Joining the Move More WhatsApp Group (2) When participating in any exercise or exercise program there is the possibility of physical injury. If you engage in a Move More NI virtual physical activity session you agree to do so at your own risk, you are voluntarily participating in these activities, assume all risk of injury to yourself (3) Fermanagh and Omagh District Council receiving and sharing your details to record them on their database(s) and use and share them (a) to enable them (and/or a Macmillan Mover More Coordinator or other representative acting on behalf of the Participating Organisation) to get in touch with you by text and/or by email and/or by post about Move More and the related services and (b) so that they can tailor the services to suit your needs and provide you with the right information and support. (4) Your details being shared with Macmillan Cancer Support so that Macmillan can (a) assist the Participant Organisation to provide the Move More services and (b) understand who is coming along to the service, the difference that the service is making and how the service can be improved but your personal data will not be kept by Macmillan. The details of Macmillan maybe found at https://www.macmillan.org.uk/terms-and-conditions/privacy-policy.html. Your personal information will be held and used in accordance with the Data Protection Act 2018. Fermanagh and Omagh District Council promises to keep your details safe and never sell or swap them with anyone else.
Signature
Date
*
-
Month
-
Day
Year
Submit
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