Neuro Activator Walking Programme - Expression of Interest Form
6 week Activator Walking Pole programme for individuals with Neurological Conditions. Please note - This is an expression of interest form only, it is not a guarantee of a place on an upcoming programme. You will be contacted by a member of the team with a separate booking link if deemed appropriate to attend an upcoming programme. Thank You.
Pilot Programme
We will be running initial 6-week Activator Walking Pole programmes in North Cork from September. We welcome expressions of interest for the upcoming programmes at this time. Dates will be confirmed shortly and issued to those who have expressed an interest.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Location (eg. Mallow)
*
How did you hear about the programme?
*
Do you use a walking aid?
*
Yes
No
What if any walking aid do you usually use to get around outdoors?
What if any walking aid do you usually use a get around indoors?
Have you had any falls in the last 6 months?
*
Yes
No
If yes, how many falls have you had in the last 6 months?
Data Sharing (GDPR)
Please note: This data will be shared with MS Ireland. By clicking "submit" you are giving consent for your data to be shared by Cork Sports Partnership for the purposes of the Activator Walking Pole programme only. For any queries please contact Eoin Kaar on 086-1409225.
Submit
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