Walking Football - Registration Form
Privacy and Consent (PLEASE NOTE WHEN SUBMITTED YOU CAN ATTEND THE SESSION YOU SHOULD NOT WAIT FOR A REPLY)
I consent to Newcastle United Foundations Privacy Policy.
Please Select
No
Yes
Which Programme are you attending?
Which programme are you attending? (Walking Football)
Walking Football - Weekly Sessions
Walking Football - Dementia Session at NUCASTLE
Walking Football - Dementia Session at Alnwick
Walking Football - Dementia Session at Berwick
Walking Football - Headway Session
Walking Football - Women's Only Session
Walking Football League - Cochrane Park Session
Walking Football - Ashington Hirst Welfare
Contact Information
Forename
Surname
Date Of Birth
Day
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
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26th
27th
28th
29th
30th
31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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2003
2002
2001
2000
1999
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1981
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Mobile
Email
Demographic
Gender
Please Select
Female
Male
Non-binary
Other
Prefer not to say
Transgender Female
Transgender Male
Other
Ethnicity
Please Select
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Chinese
Asian/Asian British - Bangladeshi
Asian/Asian British - Other
Asian/Asian British - (Unspecified)
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - Other
Black/African/Caribbean/Black British - (Unspecified)
Mixed/multiple ethnic groups - White and Asian
Mixed/multiple ethnic groups - White and Black African
Mixed/multiple ethnic groups - White and Black Caribbean
Mixed/multiple ethnic groups - Other
Mixed/multiple ethnic groups - (Unspecified)
White - Welsh/English/Scottish/Northern Irish/British
White - Irish
White - Gypsy, Roma or Irish Traveller
White - Eastern European
White - Other
White - (Unspecified)
Other ethnic group - Arab
Other ethnic group - Other
Prefer not to say
Religion
Please Select
No religion
Christian (all denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Other
Disability
Please choose a value
Yes
No
Prefer not to say
If you do have a disability please tick the relevant box below
Hearing impairment (deaf or hard of hearing)
Learning difficulty (e.g. movement co-ordination difficulty (Dyspraxia, Dyslexia, etc.)
Learning impairment/disability (eg. Down's syndrome, etc)
Long term illness (eg. cancer, HIV+ etc)
Mental health condition (eg. depression, schizophrenia etc)
Physical impairment - ambulant (I do not use a wheelchair)
Physical impairment - wheelchair user
Social/communication impairment (eg. autistic spectrum disorder, Asperger's syndrome etc)
Visual impairment (blind or partially-sighted)
Other
Prefer not to answer
Sexual Orientation
Please Select
Straight or Heterosexual
Gay or Lesbian
Bisexual
Prefer not to say
Other
Address
Address line 1
Address line 2
Post Code
Medical Information
In the event that I get injured while attending a course or activity, I give my consent to receive medical attention.
Please Select
Yes
No
Not Given
Do you have any medical conditions or require medication to safely participate in a session?
Please Select
Yes, I have a medical condition and require medication
Yes, I have a medical condition but do not require medication
No, I do not have any medical conditions or medication requirements
Prefer not to say
Other
What medical condition do you have?
Please Select
ADHA
ADHD
Allergies
Anxiety
Asthma
Brain Injury
Cancer
Cancer1
Chrons
DVT
Dementia
Depression
Diabetes
Epilepsy
Functional Neurological Disorder
Hiatus Hernia
High blood pressure
Marfan Syndrome
None
Osteo Arthritis
Other
Prefer not to say
Schizophrenia
Do you take any medications that you think we should know about (for a disability or medical condition) that might impact your participation in this programme?
Do you have any access requirements that we need to be aware of?
Emergency Contact Details
Emergency Contact Forename
Emergency Contact Surname
Emergency Contact Mobile
Emergency Contact Relationship to Participant
Declaration
I confirm that I have provided consent to take part in this programme
Please Select
Yes
No
The information provided in this form is to the best of my knowledge and is accurate
Please Select
Yes
No
Newcastle United Foundation would also like to obtain photography and videography for evaluation and publicity purposes - Please tick below the additional information you are happy to consent to.
I provide consent for my images to be used for evaluation and publicity.
I provide consent for my images to be shared with Newcastle United Football Club.
I do not consent
I provide consent for images being used for reporting only.
Do you give consent for Newcastle United Foundation to send you news and updates to your registered email address?
Please Select
Yes
No
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