(Phase 3) 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.

Question Title

* 1. Full Name

Question Title

* 2. Date of birth

Date of birth

Date

Question Title

* 3. Age

Question Title

* 4. Ethnicity

Question Title

* 5. Religion

Question Title

* 6. Gender

Question Title

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

Yes

Prefer not to say

Question Title

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

Straight/heterosexual

Bisexual

Gay man

Lesbian/gay woman

Other

Prefer not to say

Question Title

* 9. Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Question Title

* 10. Email

Question Title

* 11. Phone number

Question Title

* 12. Emergency Contact 1

Name

Relationship to you

Phone Number

Question Title

* 13. Emergency Contact 2

Name

Relationship to you

Phone Number

Question Title

* 14. GP Practice

GP Surgery Name

Address

City/Town

ZIP/Postal Code