Silver Joggers Participant Registration Form GO Active Participant Registration Form Question Title * 1. Are you new to Silver Joggers No Yes If yes, where did you hear about this activity? OK Question Title * 2. What is your Name? OK Question Title * 3. Are you... Male Female Prefer not to say OK Question Title * 4. How old are you? 16-19 20-34 35-54 55-64 65-74 75+ OK Question Title * 5. What is your postcode? OK Question Title * 6. What is your email address? OK Question Title * 7. What is your telephone number? OK Question Title * 8. What is your ethnicity? White Mixed Asian/Asian British Black/Black British Chinese/Other Prefer not to say Other (please specify) OK Question Title * 9. 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 * 10. Do you have a long term illness, health problem or impairment that limits your daily activities? Yes No Prefer not to say OK NEXT