Active Steps - Cancer

Active Steps - Registration Form

Active exercise recovery from Cancer Programme
Register your interest in our FREE 6-week Active exercise recovery from Cancer programme.

Completing this form does not commit you to attending. We will contact you within the next 7 days to discuss suitability and next steps.

This project is funded by Weston Park Cancer Charity and delivered by Zest.

If you have any questions, please call 07845 755 000 to discuss before submitting.
Please confirm:*

I confirm I am over 18 years old and have been medically cleared by my doctor or consultant to participate in physical activityI have received treatment for my cancer (surgery, radiotherapy, chemotherapy, immunotherapy) within the last 6 months
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 - Wed 18th November - Wed 6th January 18:00-19:00Active Steps - January - March - Dates tbc
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
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Active Steps - Registration Form