The Silver Line Project

Application Form for 3 week Physical Activity Programme

Please email your completed application form to

Title / Mr / Mrs / Miss / Ms / Other
Forename(s)
Surname
Date of birth
Gender / Female / Male / Transgender
Address
Postcode
Tel (home)
Tel (mobile)
E-mail
Ethnicity
Asian or Asian British - Bangladeshi / Asian or Asian British – Indian / Asian or Asian British - Pakistani
Asian or Asian British – Other / Black or Black British – African / Black or Black British - Caribbean
Black or Black British – Other / Chinese / Mixed – White and Asian
Mixed – White and Black African / Mixed – White and Black Caribbean / Mixed – Other
White British / White Irish / White - Other
Other Ethnic Group / Prefer not to say
How did you hear about the programme?
Publicity material / Referred by another organisation (please give details)
Recommendation by friend / family member / Other(please give details)
Details:
Why do you want to take part in this programme?
Please give brief description of your current level of physical ability including any injuries or medical conditions.
Please give brief description of any past injuries or health issues.

Physical Activity Readiness Questionnaire: PAR-Q- Adult Participants

Regular physical activity is fun and increasingly more people are starting to become active every day. Being more active is a very safe for most people. However, some people should check with their doctors before becoming much more physically active.

Please answer the questions below regarding your health. They will indicate whether you should check with your doctor before embarking on a programme of exercise. If you are over 60, we recommend that you should complete this questionnaire and consult your doctor even if you answered NO to all the questions.

Common sense is your best guide when you answer each of these questions carefully and honestly.

Tick YES or NO

Questions / YES / NO
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 are 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 activities?

If you answered YES to one or more questions or if you are over 60

Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and to which questions you answered YES.

  • You may be able to do any activity you want – as long as you start slowly and build up gradually. Or you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kind of activities you wish to participate in and follow his/her advice.
  • Find out which community programmes are safe and helpful for you.

If you answered NO to all questions

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:

  • Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.
  • Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.

When to delay the start of an exercise programme

  • If you are not feeling well because of a temporary illness such as a cold or a fever, wait until you feel better before exercising.
  • If you are or may be pregnant, talk to you doctor before you start becoming more active.

Please note: If your health changes so that you would answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Informed use of the PAR-Q; Poplar HARCA and The Silver Line Project assume no liability for persons who undertake physical activity. If in doubt after completing this questionnaire, consult your doctor prior to physical activity.

Emergency Contact Details

Please provide details of someone who can be contacted in case of an emergency:

Title / Mr / Mrs / Miss / Ms / Other
Forename(s)
Surname
Address
Postcode
Tel (home)
Tel (mobile)
Declaration

In signing and dating this registration form, I hereby acknowledge that:

  1. I am aged 18 or over
  1. I have completely the form accurately and honestly, and give the information on this form in confidence but without any liability on the part ofThe Silver Line Project, Poplar HARCA or any of the respective organisations’ employees.
  1. I give my permission for the use any of the personal details provided in order to communicate with me, either orally (telephone), electronically (text and e-mails), or in person (home visits) unless I have provided written instructions to the contrary.
  1. I understand that my details will be shared across project delivery partnersand that my details will only be passed on to other organisations with my prior consent.
  1. I have read, understood and completed the Physical Activity ReadinessQuestionnaire (PAR-Q). I have consulted my doctor about any YES answers or because I am over 60, and have been advised that I can exercise.

Name: / Signature: / Date:
OFFICE USE ONLY
Poplarresident / Satisfactory PAR-Q
Declaration signed / Emergency contact provided
Shortlisted for programme / Checked by: