WalkingSTONES Membership 2024

The Gallagher Stadium,
James Whatman Way, Maidstone,
Kent ME14 1LQ,

info@stonesct.org.uk

Registered Charity No. 1184274
Walking Stones

Membership Form 2024
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Date of birth

DayMonthYear
Date
Do you have any disabilities we need to be aware of?
Please provide details of any health conditions
Do you have any existing medical conditions?
Please provide details of any health conditions
Are you taking any medication?
Please provide details of any health conditions

What are your main reasons for starting this programme?

	Yes	No
Has your doctor ever said you have a heart condition that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had a chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example back, knee, or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing medication for your blood pressure or a heart condition?
Do you know of any other reason why you should not take part in physical activity?

If you have answered 'Yes' to the 'Any other reason' question above please provide more details:
I.C.E (In case of an emergency) contact name
I.C.E (In case of an emergency) contact telephone number*

Area CodePhone Number
If you have answered 'Yes' to one or more questions above you should consult with your doctor to clarify it is safe for you to become physically active at this current time and in your current state of health.

If you have answered 'No' to one or more questions it is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
A fitness appraisal can help determine your ability levels.

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury
By signing this form you are confirming that you are consenting to WalkingSTONES a programme of The Stones Community Trust, holding your details for use in case of a medical emergency and, in addition, also hold your contact details on our WhatsApp Group and the sharing of information on the Group.

You can withdraw your consent at any time by contacting the Trust or a member of the Walking Football committee.
Signature*

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Date*

DayMonthYear
Date
Name*
Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.
Name
Signature

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Walking Stones