Strength and Balance / Chairobics booking

Current participation
1. Are you currently attending Chairobics or Strength & Balance Classes?
  
  Yes
  
  No
2. Current participants cannot book on to the next cohort until 1 week before the new class starts.
Booking
1. Participants first name
2. Participant last name
3. Date of birth
  
  Day
  
  Month
  
  Year
4. Participant age
5. Gender
6. Postcode
7. Contact number
8. Email address (optional)
9. Do you consider yourself to have a disability?
  
  Yes
  
  No
10. Do you hold a Hillingdon First card?
  
  Yes
  
  No
11. HFC number (optional)
12. Are you a Hillingdon resident? (optional)
  
  Yes
  
  No
13. Is this a self-referral?
  
  Yes
  
  No
14. Who were you referred by? (optional)
15. GP surgery details
16. Postcode
17. On average how many minutes per week do you spend being physically active that raises your breathing rate?
18. Data sharing statement: all details provided will be shared with the exercise instructors. Details will also be provided to venues hosting classes.