*Given Name:

*Family Name:

*Address:

*Email Address:

Birthdate

Gender
Male
Female
Other Rather not say

Concession Card:
Yes
No

Card Number:

*Primary Phone:

Secondary contact: (home or mobile phone)

Work Phone:

Country of Birth

Main language spoken at home:

Do you speak English?
Very well
Well
Not well
No

*I would like to express interest in enrolment in:

Have your attended a course at the Centre before?
Yes
No

How did you find out about the course?
Course guide
Website
Poster
Word of Mouth
Facebook
Twitter
Instagram
Other

*Emergency Contact Name:

*Relationship:

*Emergency Contact number:

Other contact number :

Do you have a medical condition that staff should be aware of?
Yes (if yes, please complete 'Part B' below
No

In the event of an emergency, I consent to staff of the Centre seeking, or where appropriate, administering, such emergency treatment as is reasonably necessary and that I will reimburse any necessary expenses incurred by the Centre.
Yes
No

I give consent to be photographed by the Centre staff or a representative from the media. I understand that photographs may be used in a range of media, including hard copy and electronic formats. Photos taken at the Centre will only be used to promote the Centre and for no other purpose.
Yes
No

I would like to receive, by email, class updates; reminders; newsletters etc. I can cancel anytime by contacting the office.
Yes
No

Our aim is to ensure you have an enjoyable, learning experience. Please provide any information that will assist us. For example, if you have poor eyesight we can help by using large print on written material, seating you closer to whiteboards, or by changing to a bigger resolution on computer screens.

Medical and Mobility sections are compulsory before attending an exercise class such as Gentle Exercise or Tai Chi.

Please tick all boxes that apply to you. Thank you.

Are there any medical areas that we should be aware of?
None
Diabetes - Hypoglycemic
Epilepsy - Seizures
Heart condition
Hearing
Eyesight
Memory Loss
Mental health (eg: depression)
Medication that might impair judgement or balance
Physical issue or other (please specify):

Medical emergency action plan: Common signs or symptoms of condition:

Action plan:

Do you have any areas where we can support you with mobility?
None
May have problems with steps
Can become unsteady at times - easily fall
Use a mobility aid / walking stick / frame
Use a wheelchair
Has arthritis in:

Other

How do you socialise with others?
Enjoy learning in small groups
Need encouragement to join in
Prefer to work alone
other

What is your preferred communication style?
Conversation/Talking
Written
Signs/symbols
Communication aids
Respond to yes/no
Simple directions

How do you prefer to learn?
Listening
Seeing
Hands-on / doing
Reading
Pictures
Reflection - need time to take it in
Repetition
Other