ParaCheer Workshop Booking

ParaCheer Workshop Booking Form

Please provide as much detail as possible, so we can best meet your needs and provide a great workshop experience!
Which workshop(s) are you booking for?*

20th January 2018 - Wycombe
Will you be attending the workshop as a Coach or an Athlete?*

CoachAthlete
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender Identity*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number*

PrefixPhone Number
E-mail Address*
Emergency Contact Details - please tell us one or two people who we can contact during the workshop in the event of an incident or emergency situation.

Emergency Contact 1: Name

First NameLast Name
Emergency Contact 1: Phone Number

PrefixPhone Number
Emergency Contact 1: Relationship to you
e.g. Mum, Dad, Partner, etc

Emergency Contact 2: Name

First NameLast Name
Emergency Contact 2: Phone Number

PrefixPhone Number
Emergency Contact 2: Relationship to you
e.g. Mum, Dad, Partner, etc

Do you have any previous cheerleading experience?*

YesNo
You selected "Yes" - please tell us how many years cheerleading experience you have and at what level?
You selected "No" - please tell us if there are any other sports or physical activities you have experience with?
Approximately how many hours of physical activity do you undertake per week?*

0-1 hour1.5-3 hours3.5-5 hoursOver 5 hours
What are you hoping to learn or experience at this workshop?
Do you consider yourself to have a disability or any additional support / access needs?*

YesNo
What is your disability or medical diagnosis?
Please select as many options below as apply to you:

Physical DisabilityLearning Disability / Special Educational NeedsSensory DisabilityMental Health difficultiesVisual ImpairmentDeaf or Hearing ImpairedMobility ImpairmentLong Term InjuryOther
What effect does your disability have on you physically? What physical adaptations do you require?
What effect does your disability have on your interactions with others? (For example - communication difficulties, fatigue, anxiety, tics, etc.)
If you use any mobility aids or equipment, please tick these below:

Manual WheelchairPower WheelchairCrutchesProsthetic LimbWalking FrameWalking StickHearing AidsGlasses (only tick if you are unable to use Contact Lenses for the workshop)CaneGuide Dog or Assistance DogOther
Are you able to transfer out of your wheelchair to the floor, and back into your wheelchair again, unaided?

YesI can transfer out to the floor, but require assistance to get back in againI can transfer in from the floor, but require assistance to get out and onto the floorNo - I require a person to assist me both in and outNo - I require a hoist to transfer both in and out
Are you currently taking any medication? Please provide details below or type "No".*
This information may be used in the event of an emergency or incident requiring medical treatment.
If you are registered with a GP surgery, or have a specialist who should be consulted in the event of a medical incident, please provide their details below: (this can be just the name of your registered GP clinic or type "none" if you are not registered)*
This information may be used in the event of an emergency or incident requiring medical treatment.

Workshop Fee*

Coach - Workshop Attendance£35.00

Number of Workshops you are booking for:

Athlete - Workshop Attendance£20.00

Number of Workshops you are booking for:

Enter coupon

Total £0.00

Add me to the ParaCheer International mailing list for occasional email updates and news of events and workshops:

Yes please!
Send me information about ParaCheer International's membership package:

Yes please!
I would be interested in hosting a workshop in my area in future - please send me details about hosting workshops:

Yes please!
Should be Empty:

ParaCheer Workshop Booking Form