Rowing For All

Section 1: Participant Contact Details

Participant Name: Gender:


Age:

Section 2: Parent/guardian & emergency contacts (Please provide two contacts)

Name 1: Tel. No:

Name 2: Tel. No:

Email Address:

Section 3 Disability Information

Please select which category reflects your primary disability/impairment

Autism Aspergers

Please give additional information you feel the Rowing instructor should be aware of.

Section 4: Standard Physical Activity Readiness Questionnaire

Please read carefully and circle Yes or No opposite the question if it applies to you.

1.Do you have chest pain brought on by physical activityYesNo

2.Have you developed chest pain at rest in the last month or are you on any

prescribed medication for a heart conditionYesNo

3.Do you ever feel faint, have dizzy spells or lose consciousnessYesNo

4.Has your doctor ever diagnosed you with having high blood pressure or are you

currently on any prescribed medication for high blood pressureYesNo

5.Do you have a bone or joint problem that may be aggravated or made worse by

participating in physical activityYesNo

6.Have you been hospitalised within the last three to six months

If yes please provide further detailsYesNo

7.Has your doctor ever indicated that you shouldn’t take part in physical activity? YesNo

  1. Is there any reason that you are aware of as to why you shouldn’t take part in YesNo

physical activity?

  1. Are you currently on any medication? If yes please provide further details Yes No
  1. Please indicate if you have any of the following conditions?
    Epilepsy: Yes No Diabetes: Yes No Asthma: Yes
  1. Please provide additional information you feel necessary for the instructor/coach to
    be aware of to make sure the programme is a positive experience for all participants.

Section 5:

Consent for Photography/Recordings/Media Release

I consent to the use of photographs or video footage to promote the Rowing For All programme on the Cork Sports Partnership website, in newsletters and publications as well as (in some cases) distribution to National Organisations such as the disability service provider, CARA National APA Centre, Sport Ireland and National Governing Bodies of sport.

Yes No

Section 6: Declaration

I declare that all information provided on this form is complete and accurate. I understand and agree that this form can be reviewed by the activity leaders/instructors who will be leading the sports/activity sessions.

Signed ______Date ______

All information will be processed in accordance with the Data Protection Amendment Act 2003