Registration Form
Please complete both sections of the form and return both to your Group Leader who will retain part 1 and return part 2 to the local Jog Northants project coordinator at Northamptonshire Sport.
Part 1: Disclaimer & Personal Details: This section will be retained by your group leader. Please print your details clearly, complete in full and return to your group leader
Full Name:
Address:
Postcode:
Telephone Number (including STD Code):
Email:
Next of Kin (or person to contact in case of accident/illness):
Address of next of kin (If different from your own)
Postcode:
How did you hear about the group?
What would you like to get out of the group?
To get fitter To lose weight To meet new running partners
To run local events To improve
Are you currently involved in any other forms of exercise? Yes No
If yes, what type and how often?
Have you done any running before? Yes No
If yes, what type and how often?
Do you have any health considerations we should know about?
Yes No
If Yes, please explain......
......
Do you suffer from any of the following? Diabetes Heart Problems Joint Problems High Blood Pressure Asthma Back Pain
Previous Injuries
Any conditions requiring medication (please Detail):
Next of kin telephone number:
PLEASE READ THE FOLLOWING AND SIGN BELOW
Signed: ......
Date:......
Running Group Leaders are qualified leaders and are willing to share their experience and enjoyment of the sport with me. I can confirm that I understand that participation in this group is entirely at my own risk and should consult my own doctor if suffering from any condition that might make running injurious to my health.
Part 2: Registration Information: Your group leader will send this section to the local project coordinator. Please print your details clearly, complete in full and return to your group leader
What form did this exercise/activity normally take? For example running or cycling.
What would you like to get out of the group?
To get fitter To lose weight To meet new running partners
To run local events To improve
Before joining this group – were you new to running?(not involved in running for the past 12 months or more)
Yes No
Disability: Do you have a longstanding illness or disability? Yes No
Name of Jog Northants Group or Leader:
Ethnicity:
Surname:
Forename:
Before joining this group - how often did you exercise?
In an average week before joining the jogging group, how many days did you do a total of 30 minutes or more of physical activity, which was enough to raise your heart rate?
0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days
Title: Mr Mrs Miss Ms Other:
Date of Birth: (DD/MM/YY) _ _ / _ _ / _ _
Gender: Male Female
House Number:
Town:
Postcode:
Email: