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Please fill in the following form so we can learn a little bit more about you.

Personal Information

Date of Birth

Contact Information

Disabilities

DO YOU HAVE A DISABILITY?

If 'yes' please state what:

Activity Levels

In the past week, on how many days have you done a total of 30mins or more physical activity which was enough to raise your breathing rate?

What are your main reasons for getting more active? (Tick as many that apply)

Tick all that apply

Health

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical activity?

If 'yes' please state what:

If you answer yes to any of these then we recommend you see your GP 
for advice before exercising.

By ticking the box below I confirm that I agree for my personal details to be shared with Trust Thamesmead and Charlton Athletic Community Trust for them to contact me to discuss becoming and staying active.

All the information collected will be processed and held securely under the principles of the Data Protection Act 1998.

The information you provide will be used by the Now’s the Time project to stay in touch with you to encourage you to become active and stay active. Your data will be shared with the London Borough of Bexley so it can keep track of the numbers taking part in the activities but not in a way that would allow them to identify who you are.

For Greenwich residents only, your data will be used by the Greenwich Get Active Programme (GGA) and shared with the Royal Borough of Greenwich to encourage you to become active and stay active, and track the numbers taking part in GGA activities.

The London Borough of Bexley is what we call the ‘Data Controller’. They are responsible for the safe and secure collection of your personal information. Trust Thamesmead and Charlton Athletic Community Trust are what we call the ‘Data Processors’. They will safely and securely organise, retrieve, use or destroy your information. They will also share it with each other so that we can stay in touch with you and give you a free Access Thamesmead Card.

I accept:


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