Melton Sport and Health Alliance

* Required Field

Melton Borough Council will use the data contained on this form to monitor and evaluate sessions to enable us to demonstrate the impact to funders Active Together (local Active Partnership) and Leicestershire County Council; to help improve our activities for the benefit of the local community; and to promote further physical activity opportunities to you from time to time.

Name of Session:*

Are you happy to receive contact (if required) by email/phone?*

Name*:

Age*:

Post Code*:

Contact Number*:

Contact Email*:

What best describes your gender?*

Which one of the following best describes your ethnic group or background?*

Do you have any physical or mental health conditions that have lasted or expected to last 12 months or more? Please tick all that apply.*

In the past week, how many minutes of physical activity have you done in total, which was enough to raise your breathing rate?*

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?*

In the past week, on how many days have you done exercises that strengthen your muscles*:

How would you rate your mental health in general?*

Participation Declaration*:

It is your responsibility to seek medical advice before taking part in any physical activity if appropriate. It is your responsibility to provide and administer your own medication if appropriate. It is your responsibility to inform the instructor if there is a change in your health.

Please tick here to confirm that you have read and understood the participant declaration.

Data Protection: For information about how & why we may process your personal data, your data protection rights or how to contact our data protection officer, please view our Privacy Notice (http://www.melton.gov.uk/info/200240/data_protection/1132/privacy_notices/23).
Please note photography and video may be taken at council events, which may be published on social media, promotional material and websites. Although we will always try to make it clear when photographs are taken, if you do not wish to be in any photos or video, please let the instructor know.

Pre Questionnaire