Walks n Talks Program

Walks n Talks Program

with Dr Jo Chaffer
Registration Form
Please consider the questions below carefully and provide as much detail as possible.

All due care will be taken to guide you on the Walks n Talks Program. However, you should be aware that physical activities can be strenuous and may result in injury.

We recommend that you consult a doctor for a physical examination and other advice before commencing any exercise regime.

Please complete our Risk Waiver form and email it back to us at cancer.information @actcancer.org

Risk Waiver Form

Feel free to call us on (02) 6257 9999 if you have any questions.
Section 1: Personal Details
Name*

First NameLast Name
Email:*
example@example.com
Phone Number*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

DayMonthYear
Date
Gender:*

MaleFemaleI prefer not to sayI prefer to self identify:
Section 2: Cancer Treatment
Cancer Type(s):*
Date of diagnosis: *

DayMonthYear
Treatment Received:*

SurgeryRadiotherapyChemotherapyHormonalOther
Treatment Status:*

CompleteIncomplete; Provide details below:
Date completed treatment:*

MonthDayYear
Date
I am receiving long term treatment:*

NoYes; Provide details below:
Where did you receive your treatment?*
Section 3: Screening
Are you able to safely participate in a Walk n Talk?*

Yes - no limitationsYes - with the following limitations:

The following questions are about your capacity to undertake the Walk n Talk:*

	Yes	No
1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to loose balance?
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5. If you have diabetes (type I or type II), have you had trouble controlling your blood glucose in the last 3 months?
6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
8. Do you suffer with Lymphoedema?

Please provide details for all questions you responded 'Yes' to in Sections 4:
Is there anything that makes exercise difficult for you?*
Do you have any allergies? Do you take any medications? Please provide the names of your medications including allergy medication: *
You should consult a doctor particularly if you have ever experienced a heart condition, stroke, unexplained chest pains, faintness, dizziness, shortness of breath, severe asthma, diabetes, muscle, joint or bone problems or any other medical conditions that may make it dangerous for you to participate in physical activity.

Regardless of whether you consult a doctor, you agree that by participating in the CancerCouncil ACT programs, you do so entirely at your own risk. You agree that you are aware of the risks of participation in the Walks n Talks program and you voluntarily agree to assume those risks.

Please complete our Risk Waiver form and email it back to us at cancer.information @actcancer.org
Section 4: Program recruitment
How did you hear about the Walks n Talks program?*
By submitting this form, you consent to the review of your provided answers and acknowledge that we may contact you for additional questions in order to evaluate your eligibility for participation in the Walks n Talks program. Please note that Cancer Council ACT reserve the right to decline your participation if our healthcare professionals, after careful consideration, determine that your participation may not be suitable or safe for your own well-being. Your safety and health are of paramount importance to us, and we appreciate your understanding in this matter.
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Walks n Talks Program

Registration Form

Section 1: Personal Details

Section 2: Cancer Treatment

Section 3: Screening

Section 4: Program recruitment