Walking Football - Registration Form
Privacy and Consent
I consent to Newcastle United Foundations Privacy Policy.
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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
Contact Information
Forename
Surname
Date Of Birth
Mobile
Email
Demographic
Gender
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Female
Male
Non-binary
Other
Prefer not to say
Transgender Female
Transgender Male
Ethnicity
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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
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No religion
Christian (all denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Other
Disability
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Yes
No
Prefer not to say
Disability - please state
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
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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 choose a value
Yes
No
Not Given
Do you have any medical conditions or require medication to safely participate in a session?
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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?
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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
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Yes
No
The information provided in this form is to the best of my knowledge and is accurate
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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?
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Yes
No
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