Aimee McKenna - CW (Adult) Programme Registration Form

CW Programme Registration Form

CWC = Aimee McKenna
Section 1

Participant Information & Permissions
Name*

ForenameSurname
Contact Number*
Mobile or Landline
Email (for all correspondence inc. confirmation)*

Confirmation EmailPlease confirm email address
** Information regarding programme(s) will be communicated via email. Please ensure that you check your junk / spam folder regularly encase correspondence gets diverted **
Gender*
Please select response via drop-down menu
Age*
Min. Age 18
Date of Birth*

DayMonthYear
Day-Month-Year Format
Do you have a disability that the coach needs to be aware off?*

YesNo
Please provide details regarding disabilty*
Do you have any medical considerations (inc. allergies) that the coach needs to be aware off?*

YesNo
Please provide details regarding medical considerations *
Images (photographs and videos) might be taken during programmes, sessions, activities etc. Images taken may be used for Council publications, promotional purposes etc. including online and shared with partner organisations (for example, Public Health Agency (PHA), Western Health and Social Care Trust (WHSCT) etc. as required.
Do you give permission to be included within photographs and/or videos associated with programme, session or activity being attended?*

YesNo
Section 2

Participant Monitoring
The following questions and responses will enable Fermanagh and Omagh District Council to review and monitor programme delivery across the district area.
Participant Post - Code *
Input Example = BT74 7BA
Which racial group do you consider you belong?*

BangladeshiBlack AfricanBlack CaribbeanBlack (Other)ChineseIndianIrish TravelerMixed Ethnic GroupPakistaniWhiteOther
Section 3

Participant / Programme Disclaimer
You (the named participant as detailed in Section 1) accepts that Fermanagh and Omagh District Council, partner organisations or coach associated with programme, session or activity delivery are not liable for any injury or harm that is sustained as a direct result of engagement within the programme, session or activity and you are participating entirely at your own risk.

You (the name participant as detailed in Section 1) should only engage in the programme, session or activity if fit and well to do so. You will participate within the confines of your own capability and seek medical advice if required prior to commencing programme, session or activity.
Please confirm that you have read and understood the disclaimer in Section 3*

Yes
Section 4

Programme Selection
Please select programme(s) you wish to attend from the options available below.
Commencing 25 September (Chair Exercise)
Commencing 25 September (Couch to 5k)
Commencing 2 October (Walking Group Fintona)
Commencing 30 September (Step Challenge Walking Programme)
** Please note, Step Challenge - Sure Start ( Gortin Road) is not available for public registration**
Commencing 1 October (Circuits)
Commencing 8 October (Boccia)
** Please note, Boccia at Camphill Clanabogan is not available for public registration**
Commencing 18 October (Buggy Walk)
Commencing 7 November (Chair Exercise & Boccia)
Section 5

Emergency Contact Information
Please provide emergency contact details below. Please ensure that you have permission from the nominated emergency contact(s) to provide their information.

Emergency contact 1 (primary) will be contacted in the first instance. Emergency contact 2 (secondary) will be contacted if the primary contact does not respond.

Emergency Contact Information *

	Name	Contact Number
Emergency Contact 1 (Primary)
Emergency Contact 2 (Secondary)

Section 6

Data Protection
In accordance with the Data Protection Act 2018, Fermanagh and Omagh District Council has a duty to protect the information we hold on you. The personal information you provide on this form will only be used for the purpose of the programme, session or activity attending. Information will be shared with partner organisations, for example, PHA, WHSCT etc. for the purpose of the programme if required however, this will not be shared with any other organisations unless law or regulation compels such a disclosure.

For further guidance on how we hold your information please visit the Privacy Section on the Council website: https://www.fermanaghomagh.com/your-council/privacy-statement
Section 7

Submission
Please review information and if all required details have been included please 'submit'.

Please note, the submission of an application form is not confirmation of a programme place. Programme places are limited and will be allocated on a first come, first served basis.

Further information will be sent in due course regarding your application and whether a place has been allocated for requested programme(s).
Should be Empty:

CW Programme Registration Form

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7