Parkinson's Football Sessions
Haverfordwest County AFC are delighted to be introducing Parkinson's Football sessions. If you, or someone you know, might be interested, please fill out this form to express interest.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you completing this form for yourself, or on behalf of someone else?
*
Please Select
Myself
Someone else (e.g. family member, friend, carer)
What age group do you/they fall into?
*
Please Select
Under 40
40-49
50-59
60-69
70+
Please select your/their gender
*
Please Select
Male
Female
Prefer not to say
Please state your/their ethnicity
*
Please state if you/they have a long-term illness or disability
*
Please state your home postcode
*
What is your/their current level of physical activity?
*
Please Select
Very active
Moderately active
Occasionally active
Not currently active
What is your/their current level of mobility?
*
can walk unassisted
uses a walk aid occasionally
uses a walk aid regularly
requires assistance from another person
Other
Have you/they played football before?
*
Please Select
Yes, regularly
Occasionally
Never but interested
Not interested in football, but may enjoy for social & fitness reasons
Would you/they be attending with a carer?
*
Yes, who will support me/them on the pitch
Yes, but not to participate
Potentially
No
Would you/they prefer a running or walking football structure?
*
Please Select
Running
Walking
Either
What benefits would you hope to gain from the sessions?
*
Improved physical fitness
Improved mobility
Social connections
Routine and structure
Love of football
Other
What slots would suit you/them best?
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Weekday mornings
Weekday afternoons
Weekday evenings
Click here to state your/their preferred times during the week
Are there any particular challenges or support needs we should consider?
*
Would you/they be interested in volunteering, coaching, or helping run the sessions in any way?
*
Please Select
Yes
No
Maybe
Where would you/they prefer to attend regular sessions?
*
Ogi Bridge Meadow 3G
Local sports hall
Other
Would you be interested in engaging in community activities post-session, such as a coffee & catch-up?
*
Please Select
Yes
No
Maybe
Do you/they have any other comments, suggestions, or questions for us?
*
Are you happy to be added to Haverfordwest County AFC's mailing list?
*
Please Select
Yes
No
Submit
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