Physical Activity Questionnaire

PHYSICAL ACTIVITY QUESTIONNAIRE

Dear Athlete,

Walking Netball is finally here and taking off in Gloucestershire. We will be hosting a series of walking netball sessions on the following dates below.

The sessions will be held:-

Rednock Sports Centre, Rednock Drive, Dursley, GL11 4BX

Further details can be obtained from: / 01452 616726

NETBALL SCHOOL OF SPORT BOOKING FORM

Location:Rednock Sports Centre, Rednock Drive, Dursley, GL11 4BX

Dates:WednesdayEvenings –

Wednesday3rdJanuary 2018 then weekly on a Wednesday night through until Wednesday 28thMarch 2018

Times: 6.00 P.M. – 7.00 P.M.

Cost:If payment received in advance payable via BACS 10% Discount

£5.00 per session

Lead Host:Gilly Salter

Please fill out the information on page 2 and return back to

Payments can be made via BACS to:

Gilly Salter Sports – (Please put your name as Reference & Email Confirmation to )

Account Number: 46410568

Sort Code: 30-98-29

PLEASE NOTE NO FURTHER CORRESPONDENCE WILL BE SENT. YOU WILL ONLY BE CONTACTED IF PLACES ARE FULLY BOOKED. PLEASE REMEMBER YOU WILL NEED TO BRING PLENTY TO DRINK.

If you cannot pay via BACS, cheques should be made payable to ‘Gilly Salter Sports’ and sent to:- G S Sports Consultancy, 113aHucclecote Road, Gloucester, GL3 3TS

PHYSICAL ACTIVITY QUESTIONNAIRE

Name…………………………………………………………………………………………………………………………………

Club name (if applicable) ……………………………………. Age………. Affiliation No…………………………….

Home Address ……………………………………………………………………………………………………………………………

……………………………………………………………… Post Code ………………………………………………………………….

Home Telephone Number ……………………………………………………………………………………………………………

Email Address………………………………………………………………………………………………………………………………

Emergency Contact & Tel Number………………………………………………………………………………………………..

1. Has your doctor ever said you have heart trouble? YES or No

2. Do you frequently have pains in your heart or chest? YES or No

3. Do you often feel faint or have spells of severe dizziness? YES or No

4. Has your doctor ever said your blood pressure was too high? YES or No

5. Do you have a bone or joint problem(s) that may be worsened with exercise? YES or No

6.Do you know of any reason why you should not participate? YES or No

7.Are you or have you been pregnant in the last 6 months? YES or No

8. Do you suffer from any problems of the lower back? YES or No

9. Are you currently taking any medications? YES or No

10. Do you currently have a disability? YES or No

Medical information. Please indicate any illness, allergies, recent injuries ormedication etc.,

…………………………………………………………………………………………………………………………….………………………..

Date of last tetanus injection (if known) ………………………………………………………………………………………

Name, Address & Telephone Number of Doctor ………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………….

Photographs & Video footage may be taken during the training session for use by Gilly Salter Sports Website, Facebook & Twitter, Local Media and or Netball in Gloucestershire, Netball South West & England Netball. Please notify the organisers if you personally have any objections for youto be used as part of this process. At no stage will names be listed with photographs.

Signature……………………………………………………………Printed Name …………………………………………………………

Date …………………………………………………………………………………

If you are unable to pay online, Cheques can be made payable to ‘Gilly Salter Sports’ and sentto:-G S Sports Consultancy, 113a Hucclecote Road, Gloucester, GL3 3TS