Guys Get Active Participation Questionnaire

Personal Information

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* 1. Contact Details

Full Name

Address

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 2. Date of Birth

Please input DD/MM/YYYY

Date

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* 3. Sex

Male

Female

Prefer not to say

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* 4. Ethnicity

White or Caucasian

Black or Black British

Mixed

Chinese

Prefer not to say

Other (please specify)

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* 5. Emergency Contact Details

Name

Relationship

Contact Number

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* 6. Is your BMI is over 27?

This programme is designed to help weight loss through nutrition advise and exercise. It is targeted at men who have a BMI of over 27.

If you do not know how to calculate your BMI please click here. Alternatively, select 'unknown' from the option below and we will contact you to help you calculate this.

Yes

No

Unknown

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* 7. Guys Get Active is part funded by Public Health Wandsworth Council. Do you live, work or are you registered with a GP in the borough of Wandsworth?

Yes I live in Wandsworth

Yes I work in Wandsworth

Yes I am registered with a GP in the borough of Wandsworth

No

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* 8. Marketing and Promotion Consent:

You will be contacted regarding your Kick the Fat programme registration via email and/or telephone.

We would like to contact you to update you on future Kick the Fat /similar programmes, events, and offers. If you are interested, please select how you would like to receive this information:

Email

Telephone

By Post

None