(Phase 2) Shape Up Core

Registration

We use this form to make sure you can safely and happily enjoy our programmes. We
need to collect your basic details, including information about your health.

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* 1. Full Name

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* 2. Date of birth

Date of birth

Date

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* 3. Age

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* 4. Ethnicity

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* 5. Religion

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* 6. Gender

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* 7. Does your gender identity match your sex as registered at birth?

Yes

Prefer not to say

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* 8. Sexual orientation (only answer if you are over 18)

Straight/heterosexual

Bisexual

Gay man

Lesbian/gay woman

Other

Prefer not to say

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* 9. Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

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* 10. Email

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* 11. Phone number

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* 12. Emergency Contact 1

Name

Relationship to you

Phone Number

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* 13. Emergency Contact 2

Name

Relationship to you

Phone Number

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* 14. GP Practice

GP Surgery Name

Address

City/Town

ZIP/Postal Code