LA ACTIVE PROGRAM LEISURE CARD RENEWAL FORM

Hello LA Active Leisure Card Holder

You may be at the 6 month marker of having your Edinburgh Leisure card through the Looked After and Active Program. I hope that you have enjoyed the free access to gym, swim, fitness classes, and badminton courts, and used it as much as possible.By completing and returning this form, and the LA Active Program evaluation, you will gain ONE YEAR OF FREE ACCESS.

We are committed to increasing young people’s physical activity daily as per the guidelines by the NHS. Young people should have at least 60 minutes of physical activity every day, which should be a mix of moderate-intensity aerobic activity such as fast walking, and vigorous-intensity aerobic activity such as running. Therefore, we hope that by taking the cost out of your access, you were able to use Edinburgh Leisure facilities to meet these guidelines.

Your card may be due to expire. (Please contact Hayley McKenzie to find out exact expiration dateIn order to have 1 YEAR FREE access). If you have any questions, or queries, please feel free to contact me by email at or by telephone on 0131 458 2114.

Young Person’s Details / Current Card ID:
Surname: / Address: / Postcode:
First name:
M/F / DOB: / Age: / Tel no: / Email:
Since having the LA Active Card, your health has:
Not changed at all. Improved a lot

Do you think your weight is: / About right / Too heavy / Too light
Since having the LA Active Card, your physical activity has.... Not changed at all Improved a lot

Thinking of the 7 days, how much time have you been active enough to make you breathe harder and/or become sweating – including PE sessions in school?
Time / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
No time
1-30 mins
30-60 mins
60 mins +
Excluding PE sessions in school, what activities have you tried since getting your LA Active Card?
______
Have you attended any of the following: NRG Zone Open All Hours Get Going Coached activities

Young Person’s Health and Wellbeing Questionnaire

Health & Wellbeing / Please tick the box that best describes your experience over the last 2 weeks
Statements / None of the time / Rarely / Some of the time / Often / All of the time
I’ve been feeling optimistic about the future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been feeling interested in other people
I’ve had energy to spare
I’ve been dealing with problems well
I’ve been thinking clearly
I’ve been feeling good about myself
I’ve been feeling close to other people
I’ve been feeling confident
I’ve been able to make up my own mind about things
I’ve been feeling loved
I’ve been interested in new things
I’ve been feeling cheerful
I feel in control of my life
I feel too tired to do things
I have trouble getting to sleep
I have trouble staying awake
It is hard for me to walk more than a couple of streets (about 100 m)
It is hard for me to run
It is hard for me to do sports and activities
It is hard for me to lift heavy things
I feel confident when doing coordinated movement
I feel attractive for my age
I am a physically strong person
I can run a long way without stopping
I am good at most sports
Physically, I am happy with myself
My weight is normal for my age
I have access to different sport activities
Most things I do, I do well
I am flexible enough for most sports
I am good at endurance activities like running, aerobics, swimming, bicycling or skiing
Other people think I am good at sport.
I enjoy trying new things
Overall, I have a lot to be proud of.
I can swim 25 m or more
My oral health is good.
I have a balanced diet eating 5 fruit/veg per day
I have access to information about health issues
I feel accepted by peers
Nobody thinks I am good looking
I get sick a lot
I have too much fat on my body

Parent/Carer/key-worker or social workerplease complete

Surname: / Address: / Postcode:
First name:
M/F / DOB: / Organization: / Email:
Relationship to Child / Tel. No.
Do you hold an LA Active Leisure Card? Yes/No / Card ID:
Physical Activity
Since having the LA Active card, the young person’s physical activity has? / Decreased Stayed the same Increased
How many hours per week is the young person active?
What activities has the young person engaged in since having the card?
How do you rate the program for the young person? / Poor Average Good
Has the young person attended any of the following / NRG Zone Open All Hours Get Going
Since having the LA Active Carer Card, your physical activity has increased / Decreased Stayed the same Increased
What activities have you and the young person engaged in together since having the card(s)? And how often?
How do you rate the program for the carer? / Poor Average Good

Health Wellbeing Questionnaire – To be completed by Parent /Carer/Keyworker/Social Worker

1: Always fails to achieve 2. Frequently fails to achieve 3. Achieves this 4. Frequently exceeds 5. Always exceeds achieving

The young person’s physical health is as good as possible and they receive treatment when required / 1 2 3 4 5 / The young person eats a balanced diet and has an understanding of nutrition appropriate with their age and understanding / 1 2 3 4 5
The young person’s weight is normal for their age within appropriate limits according to their age and percentile / 1 2 3 4 5 / The young person exercises moderately or vigorously for 60 minutes a day and enjoys reasonable fitness / 1 2 3 4 5
The young person has access to and takes part in a variety of social, sporting and cultural activities, appropriate to their individual needs / 1 2 3 4 5 / The child has contact with family and friends that is safe and positive / 1 2 3 4 5
The young person is accepted by other children and enjoys friendships with peers at school / 1 2 3 4 5 / The young person has a variety of hobbies and interests and opportunities to develop these / 1 2 3 4 5
The young person is able to develop manual sporting skills in line with their interests and ability / 1 2 3 4 5 / The young person is able to develop social sporting skills in line with their interests and ability / 1 2 3 4 5
The young person is confident / 1 2 3 4 5 / The young person has a positive image of self / 1 2 3 4 5