MoveWell Programme Application Form

MoveWell Programme Application Form
MoveWell is a low intensity, strength-building exercise class. The class is suitable for any adult with the following conditions; Type II Diabetes, Asthma, COPD & Cardiovascular Disease who has low levels of physically activity and who is looking to gain support and confidence to become active.

Please note: You need to be able to exercise independently without the use of a mobility aid.
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Age
Please share your current medical condition(s) and any other medical information that you feel is relevant to your participation in MoveWell.
The Movewell programme is available in the following locations (please tick your preferred choice from the options below). Please note that if your preferred choice of location is not available, you will be assigned to your second choice.
Please tick your second choice from the options below
If you were referred for this class by a health professional, please provide the following details:
Health professional's name
Health professional's email
Signature
Date

MonthDayYear
Date
GDPR requirements: Please tick yes if you wish to give consent to hold your individual information on file and/or to make contact with you in future. Data will also be shared between the HSE South West Health Promotion & Improvement Department, Cork Sports Partnership, and the facility delivering the MoveWell programme.
Should be Empty: