Thank you for registering for the Sporting Memories KIT bag. The information given below, will be kept confidential and only seen by staff within Sporting Memories. The information provided will be used to distribute your KIT bag, contact you with updates and support Sporting Memories to show the impact of the activities for future project development.

Question Title

* 1. Members name

Question Title

* 2. Address including Post Code: (Please note your KIT bag will be posted to this address)

Question Title

* 3. Sporting Memories Club you attend: (if applicable)

Question Title

* 4. Gender

Question Title

* 5. Date of Birth

Question Title

* 6. Ethnicity

Question Title

* 7. Home Telephone Number

Question Title

* 8. Mobile Telephone Number

Question Title

* 9. Email address

Question Title

* 10. Do you have an existing disability of health condition that affects your physical fitness?

Question Title

* 11. If yes, would you like to tell us what this is?

Question Title

* 12. Any additional needs for participating?

This is a new project for Sporting Memories, and we want to hear about your experiences of taking part and how the KIT bag contributes to your physical activity and wellbeing. This is the first questionnaire, and we shall send you another in three months. The information you share will provide vital information on how useful KIT bag’s are, which could help Sporting Memories to grow KIT bag in the future and help us to reach more people. Your answers will be anonymised and your information stored securely. Individual data will not be shared with anyone outside the organisation; however, some non-identifiable grouped data will be shared with project funders as part of our funding requirements.

Question Title

* 13. Please tell us your favourite sports

Question Title

* 14. On how many days do you do any physical activity? This can include walking, gardening or anything that gets you moving (0-7)

Question Title

* 15. On the days you are active, for how many minutes do you usually participate in physical activity?

Question Title

* 16. Compared to other people your own age, how confident do you feel to leave the house and socialise

Question Title

* 17. I feel happy

Question Title

* 18. How often do you feel that you lack companionship?

Question Title

* 19. How often do you feel left out?

Question Title

* 20. How often do you feel isolated from others?

Question Title

* 21. How often do you feel lonely?

Question Title

* 22. How concerned or not concerned are you about falling over?

Question Title

* 23. We would like to know how good or bad your health is TODAY. On a scale from 0 to 100, what would you score yourself TODAY.?  0 is the worst health you can imagine and 100 is the best health you can imagine

0 - worst health you can imagine 100 - best health you can imagine
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

* 24. Photographic, video images and audio consent: At Sporting Memories Foundation, we produce a wide range of materials to inform people about our work that we may use in the future. The copyright of any material which is generated as a result, shall be assigned and shall be the property of Sporting Memories Foundation. Do you give permission for photographic, video images and audio consent?

Question Title

* 25. By completing this form, you declare “to the best of my knowledge I know of no reason why I should not participate in Sporting Memories activities. I take part in any activity entirely at my own risk and waive any legal recourse to damages or property arising from my participation.” By completing this form, you consent to your details being kept by us for the purposes of taking part in the project evaluation, receiving updates about KIT bag, details with associated project activities, Sporting Memories news and copies of the Sporting Pink. Our Privacy Policy is available on our website. Please visit:

 www.sportingmemoriesnetwork.com/privacy-policy 

Please add your name to act as a signature of consent

Please complete the below if you are a family member or carer and have completed the registration form with the member.

Question Title

* 26. Your name

Question Title

* 27. Relationship to the member

Question Title

* 28. Contact Telephone Number

Question Title

* 29. Email address

Question Title

* 30. Alternative address for the KIT bag to be sent if different from above

Question Title

* 31. Signature to confirm you have consent to complete with the member. 

Please add your name to act as a signature of consent

Data Protection: The Sporting Memories Foundation is committed to protecting your personal information. Your personal data, which may be held on paper or computer, is subject to legal safeguards specified in the Data Protection Act. Data will be held on a central database, which is accessed by all organisations in the Sporting Memories Group, which has a data sharing agreement in place. We will ensure that the information we hold is accurate and up-to-date.  This information will not be shared without your consent. 

T