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Why we collect your information: All information on this form, including personal information, is collected to find out more about your experiences on a Lee Valley Regional Park funded progamme and to look at what impact the sessions might have. More information with regards to how this data is used and shared can be seen on the below privacy policy.

Your name

Date of birth

Day

Month

Year

Gender

Postcode

Are you

Are your day to day activities limited because of a health problem or disability?

Yes

Prefer not to say

If yes, what is the nature of your disability or impairment?

Emergency contact (Name/phone number)

Your health and wellbeing

In the past week how many days have you done a total of 30 minutes or more of physical activity (this may include sport, exercise and brisk walking or cycling for recreation)?

Have you previously taken part in an activity/session at a Lee Valley venue or within Lee Valley Regional Park?

Yes

Physical Activity Readiness Questionnaire

Has a doctor ever said that you have a heart condition or high blood pressure?

Do you have chest pain at rest or brought on by physical activity?

Do you lose balance because of dizziness, or have you lost consciousness in the last 12 months?

Do you have a bone or joint problem that could be made worse by physical activity?

Are you currently taking any regular medication? If yes please give further details.

Are you currently taking any medication that you need to carry with you on a walk? If yes, please give further details

Has your doctor ever said that you should only do medically supervised physical activity?

I understand that if I have answered ‘Yes’ to one or more of the above questions, I should seek medical advice before attending a walking programme. I agree to tell the walk leaders if there is a change in my medical condition. I understand that this information will be shared with other walk leaders and that I walk at my own risk.

Health Commitment Statement

Your health is your responsibility. The management and staff of Lee Valley Regional Park Authority are dedicated to helping you take every opportunity to enjoy the facilities/ programmes that we offer. With this in mind, we have carefully considered what we can reasonably expect of each other.

Our commitment to you:

We will respect your personal decisions and allow you to make your own decisions about what exercise you can carry out. However, we ask you not to exercise beyond what you consider to be your own abilities.
We will make every reasonable effort to make sure that our equipment, facilities and programmes are safe for you to use and enjoy.
If you tell us that you have a disability which puts you at a substantial disadvantage in accessing our equipment/ facilities/ programmes, we will consider what adjustments, if any, are reasonable for us to make.
We will ensure our staff and volunteers are suitably trained and informed to carry out their duties.

Your commitment to us:

You should not exercise beyond your own abilities. If you know or are concerned that you have a medical condition which might interfere with you exercising safely before you use our equipment/ facilities/ programmes, you should get advice from a relevant medical professional and follow that advice.
You should make yourself aware of any rules and instructions, including warning notices. Exercise carries its own risks. You should not carry out any activities which you have been told are not suitable for you.
You should let us know immediately if you feel ill when using our equipment/ facilities/ programmes. Our staff members are not qualified doctors, but there will be a person available who has had first-aid training.
If you have a disability, you must follow any reasonable instructions to allow you to exercise safely.

This statement is for guidance only. It is not a legally binding agreement between you and us and does not create any obligations which you or we must meet.

Signed by

Date

Privacy policy

Lee Valley will retain and use your personal data for the purpose of your participation in this programme, for regulatory reasons and to provide you with information about Lee Valley. Individual data will not be shared with any third party, however, some non-identifiable aggregated data will be shared with programme funders and our members as part of our funding requirements. All data is held and used for the purpose of improving Lee Valley programmes.

We ask questions about your previous activity behavior, attitudes, feelings and thoughts to enable us to feedback to our funders and members about the impact of our programme on people’s lives. Collecting ethnicity and disability data and post codes is necessary for the purpose of identifying the existence or absence of equality of opportunity, with a view to enabling such equality to be promoted or maintained.

This information is always anonymised before it is shared with funders and members. For further information about what data we collect from you, why it is collected and what will be done with it, please see our full privacy policy here: leevalleypark.org.uk/privacy-notice

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