Nordic Walking Registration Name * First Name Last Name Email Phone number Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth MM DD YYYY Your Parkinson's Symptoms Please tick all that apply I experience symptoms on one side only I experience symptoms on both sides but have no impairment to my balance I have trouble with balance I can walk independently Any more information Fitness to exercise Has a doctor ever said that you have a heart condition or high blood pressure? yes no Do you have chest pain at rest or brought on by physical activity? yes no Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? yes no Do you have a bone or joint problem that could be made worse by physical activity? yes no Are you currently taking medication for a condition that you need to carry with you on a walk? yes no Details Has your doctor ever said that you should only do medically supervised activity? yes no Have you been diagnosed with a long term medical condition or allergy that might affect your ability to exercise? yes no Details Is there any other medical information it is important for us to know about? 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. 1 2 3 4 5 6 7 Emergency Contact Name First Name Last Name Relationship Phone number 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. You can withdraw consent for this at any time. Email kate@p4w.org.uk if you change your mind. Note: this will not apply to material already published. I consent I do not consent 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 our partners, Parkinson's UK. Walk leaders will have access to this information for your safety and to manage the walks. 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 Thank you!
