Neuro Activator Programme - Expression of Interest Form
Activator 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.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about the programme?
What neurological condition are you currently living with?
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 to 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 Pole programme only. For any queries please contact Peter Thornton on 086-1409225.
Submit
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