BOOST registration form
For referrals
Name
First Name
Last Name
Date of birth
-
Day
-
Month
Year
Date
Address
Street Address
Street Address Line 2
Neighbourhood
Town/City
Postcode
Email
example@example.com
Phone
-
Area Code
Phone Number
Emergency contact
Emergency contact: phone
-
Area Code
Phone Number
Gender
Male
Female
Another
Prefer not to say
Ethnicity
White or White British
Black or Black British
Asian or Asian British
Mixed
Other
What BOOST activity are you interested in trying? (Tick more that one if you wish)
Monday 11am: Weight training
Monday 6pm: ‘Get Onside’ Football (Monday PM)
Tuesday and Thursday: Walking (with Walk for Health)
Tuesday 7pm: non-contact boxing (women)
Tuesday 7.30pm: non-contact boxing (men. - Marple)
Wednesday 11am: non-contact boxing (mixed group)
Thursday 10am: Exercise and Nutrition (BOOST & ABL)
PHYSICAL HEALTH: Has your doctor ever said 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 pain in your chest when NOT doing physical activity?
Yes
No
Do you ever lose balance because of dizziness or ever lose consciousness?
Yes
No
Do you have a bone or joint problem that could be made worse by a change in activity?
Yes
No
If you answered yes to any of the above questions on physical health, please provide more information here:
Approximately how many hours a week do you spend taking physical activity/exercise?
MENTAL HEALTH: How would you rate your current mental health, where 10 is excellent and 1 is very poor?
Do you have any medical conditions or medication you are taking that we may need to be aware of?
Yes
No
If you answered Yes to the previous question, please provide more information here.
What is motivating you to take part in BOOST activities?
TO WHAT EXTENT DO YOU AGREE WITH THE FOLLOWING STATEMENTS? (please tick)
I am motivated to take part in the BOOST Programme
Strongly disagree
Disagree
Agree
Strongly agree
I am confident to take part in physical activity/exercise sessions
Strongly disagree
Disagree
Agree
Strongly agree
I am confident to take part in physical activity/exercise by myself
Strongly disagree
Disagree
Agree
Strongly agree
I feel supported by others to take part in physical activity/exercise
Strongly disagree
Disagree
Agree
Strongly agree
I understand the benefits taking part in physical activity can have on my mental health
Strongly disagree
Disagree
Agree
Strongly agree
How did you find out about BOOST activities and classes?
If you have been referred to BOOST by a support organisation, please provide the name of the organisation and the support worker, where appropriate.
PHOTOGRAPH/VIDEO CONSENT
I do give permission for photographs/video footage to be taken and used for publicity purposes by BOOST (e.g. leaflets, posters, social media)
Yes
No
Thank you for signing up to take part in this BOOST activity and for completing this form which will be used to help monitor the success of our programmes and help us plan future groups. Please contact steve@the-thread.uk should you have any questions.
I HAVE READ, UNDERSTOOD AND COMPLETED THIS FORM. ANY QUESTIONS I HAD WEREANSWERED TO MY SATISFACTION (if using a phone, sign with your finger)
Date
-
Day
-
Month
Year
Date
Submit
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