Active Steps - Cancer

Active Steps - Registration Form

Exercise Recovery after Cancer Treatment Programme
Due to high demand and limited spaces (just 6 participants per programme), all current places are now filled. We are actively exploring ways to secure additional funding and create more opportunities.

If you would like to be considered for future programmes, please register your interest here. We would love to hear from you.

The current two 6 week programmes are funded by Weston Park Cancer Charity and delivered by Zest.
Please confirm:*

I confirm I am over 18 years old and have been medically cleared by my doctor or consultant to participate in physical activity
Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Email*
example@example.com
Date of Birth*

MonthDayYear
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Select your preferred start date:*

Active Steps - January - FebruaryActive Steps - February - March
Please tell us a little about your cancer story*
What would you like to gain from the programme?
Do you have any other medical conditions or mobility limitations we should be aware of?*

YesNo
Please provide us with more information.
How did you find out about us
Please confirm:

I understand this is a registration of interest and not a confirmed booking.I consent to being contacted about this programme.I consent to my information being stored securely and used for programme delivery and evaluation, in line with data protection laws (GDPR).*
*ZEST takes your privacy very seriously and we will only use the information you've submitted to provide the services requested of us. Further details about the personal information we record and how it's used can be found in our Privacy Policy
Signature

Powered by Jotform SignClear
No confirmation page? Scroll to the top of the page to see any errors.
Should be Empty:

Active Steps - Registration Form