Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Other

Prefer not to say

Your walks

Which walk(s) do you intend to go to regularly? Please tick all that apply

Muir of Ord- Monday

Botanic Gardens, Inverness

Tain

Fortrose

Nairn

Glen Urqhuart

Dingwall

Tomatin

Beauly - Thursday

Beauly Short Wander - Monday

Kinmylies

Smithton

Your current activity levels

Recently, how many days a week have you been physically active for 30 minutes or more? Include anything that makes your breathe deeper, your heart beat a little faster and makes you feel warmer.

0

1

2

3

4

5

6

7

Your reasons

What are your main reasons for attending Health Walks? Please click all that apply

Manage weight

Meet new people

Feel healthier

To volunteer

I prefer walking to other exercise

How did you find out about us?

How did you hear about us. Please check all that apply

GP

Health Professional

Family/Friend

Leaflet

Facebook

Poster

Local News

Your health

Have you been diagnosed by your doctor or health professional with any of the following? Please click all that apply

Diabetes

Heart disease

Cancer

Dementia

COPD

High Blood Pressure

Overweight

Do you consider yourself disabled?

yes

no

Emergency Contact

First Name

Last Name

Photo Permission

Occasionally, Partnerships for Wellbeing would like to take photographs and/or videos of you for the following purposes: 1. To use the photos/videos on our website and on social media pages., 2. To use the photos/videos offline in our newsletters and updates to volunteers and users of our services. 3. For use in promotional materials, publications, in articles and potentially for publicity/marketing purposes. 4. To share with media or local press, and Walking Scotland (formerly Paths For All) to use in a case study. You can withdraw consent for this at any time. Email jayne@p4w.org.uk if you change your mind. Note: this will not apply to material already published.

I consent to having my photograph/video taken for the above purposes

I do not consent to having my photograph/video taken for the above purposes

Your privacy *

Partnerships for Wellbeing will store and process this information in order to manage our walking project and to communicate with you about resources, fundraising and other P4W activities. We will share your information with Paths for All for the purpose of managing the national health walk network, of which we are a member. Walk leaders will have access to this information for your safety and to manage the walks. If you are a member of the Nairn group your details will be shared with Chest, Heart and Stroke Scotland. We utilise a management software programme called coacha to store your information. Details of their terms and conditions can be found here (copy and paste into browser) https://www.coacha.co.uk/More/Legal/Terms-of-Service#NominatedUserTermsOfService For full details see our privacy policy here (copy and paste into browser) https://www.p4w.org.uk/privacy-policy The information you enter into this form will be collected and stored by Partnerships for Wellbeing in the ways described above. Tick the tickbox below to confirm you understand. *

I understand