GAGH with Diabetes Participant Registration Form 5 Swims for a Fiver Registration Form Please fill in this form as much as you can. It helps GO Active, Get Healthy to secure more funding for activities like this one! OK Question Title * 1. What centre would you like to redeem your 5 swims for a fiver voucher at? Barton Leisure Centre Ferry Leisure Centre Blackbird Leys Leisure Centre OK Question Title * 2. What is your Name? OK Question Title * 3. Are you... Male Female OK Question Title * 4. How old are you? 16-19 20-34 35-49 50-64 65-74 75+ OK Question Title * 5. What is your phone number? OK Question Title * 6. What is your email address? OK Question Title * 7. What is your ethnicity? White Mixed Asian/Asian British Black/Black British Chinese/Other Other (please specify) OK Question Title * 8. In the past week, on how many days have you done a total of 30 minutes or more of physical activity which was enough to raise your breathing rate and break out in a sweat? (This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job) None One day Two Days Three Days Four Days Five Days Six Days Seven Days OK Question Title * 9. Which of the following conditions apply to you? Learning Disability Mental Health Problems Type 1 Diabetes Type 2 Diabetes Pre-diabetes Physical Disability Other OK Question Title * 10. Disclaimer. Please tick the box below to confirm that... You are voluntarily engaging in an acceptable level of exercise and that your participation involves a risk of injury. OK Question Title * 11. For participants with one or more of the conditions listed in question 9. Please tick below to confirm that... You have sought medical advice and are aware of the increase risk and how to manage your condition. Your GP has agreed that you may exercise. OK Question Title * 12. We would like to be able to send you details of activities that might be of interest to you. Your contact details may also be retained by your instructor/coach/leader and used to contact you regarding the operation of the session you are attending. GO Active and Oxford City Council will also use your information for monitoring and evaluation in accordance with the General Data Protection Regulations 2018. Please tick here if you are happy for GO Active and Oxford City Council to contact you with information about activities which might be of interest to you via email. Please tick here if you are happy for GO Active, Get Healthy and Oxford City Council to use your information for monitoring and evaluation purposes. OK Question Title * 13. In order to register your 5 swims for a fiver voucher at your local leisure centre we will need to share your contact details with a relevant Fusion Lifestyle instructor. Please tick here to confirm you are happy for your contact details to be shared with a relevant Fusion Lifestyle Instructor. Via email Via phone call I am not happy to be contacted and I understand that this will result in me not being able to claim my 5 swims voucher. OK DONE