Box from the Mosque - Boys
This form is to be filled out by both the parent or guardian and the young person who will attend the sessions.
Personal Information
Please enter parents details where prompted
Name (of young person)
*
First Name
Last Name
Address (of young person)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (parent or guardian)
*
example@example.com
Phone Number (parent or guardian)
*
-
Area Code
Phone Number
Age of young person:
*
Ethnicity of young person:
Asian/Asian British
Black/Black British
White British
White other
Other Ethnic Group
Prefer not to say
Does your child have a health condition, a disability or a learning difficulty that we should be aware of? Please also make a note of any relevant medication they are currently taking.
Emergency Contacts
Please provide the names and numbers of two different adults we can contact in the case of an emergency:
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to young person:
*
e.g mum, sister, uncle
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to young person:
*
e.g mum, sister, uncle
Active Calderdale Monitoring (to be completed by young person)
Please be aware that this information is both anonymised and confidential
For this next question, try to add up all the time you spent doing physical activityeach day. Remember to include things like PE, anything you do at break time and lunchtime and travelling to and from school and between classrooms, and any sports clubs you attend. This week, how many days have you done more than 30 mins of physical activity?
*
1
2
3
4
5
6
7
Attitudes to Sport:
Please indicate how you feel about the following statements
I enjoy taking part in exercise and sports
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I feel confident when I exercise and play sports
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I find exercise and sport easy
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I understand why exercise and sports are good for me
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Health and Wellbeing
Overall, how happy did you feel yesterday? (Where 0 is “not at all happy” and 10 is “completely happy”)
*
1
2
3
4
5
6
7
8
9
10
Is this how you usually feel?
Yes
No
Overall, how satisfied are you with your life (if 1 is extremely dissatisfied and 10 is extremely satisfied)
*
1
2
3
4
5
6
7
8
9
10
Overall, to what extent do you feel that the things you do in your life are worthwhile?(if 1 is extremely unworthwhile and 10 is extremely worthwhile)
*
1
2
3
4
5
6
7
8
9
10
Parental consent:
Please tick this box to provide your consent for us to occasionally photograph and / or film you child participating in our activity sessions. These photos and/or films may be used for promotional purposes and feature across our marketing platforms including but not limited to: Calder Community Squash website and Calder Community Squash social media platforms. These photos may also be shared with Active Calderdale for their promotional purposes.
*
Yes
No
Submit
Should be Empty: