YMCA Welcome Day 2017 Question Title * 1. What is your name? Question Title * 2. What is your date of birth? Question Title * 3. What is your gender? Male Female Other Question Title * 4. What is your address? Question Title * 5. What is your telephone number? Question Title * 6. What is your email address? Question Title * 7. Do you/or the person attending have any injuries/medical conditions/allergies that the session staff should be aware of? (Including any current medication) Yes No Other (please specify) Question Title * 8. Do you consider yourself to have a disability? Yes No Question Title * 9. Do you consider yourself to have a mental illness? Yes No Question Title * 10. Do you have any support needs? Yes No Question Title * 11. What is the name of your emergency contact? Question Title * 12. What is the emergency contact telephone number? Question Title * 13. What is the emergency contact's relationship to you? Question Title * 14. What is your ethnicity? White/British White/Irish White/Other Mixed/White & Black Mixed/White & Asian Mixed/Other mixed Asian or Asian British/Indian Asian or Asian British/Pakistani Asian or Asian British/Bangladeshi Asian or Asian British/Other Asian Black or Black British/African Black or Black British/Other Black Chinese or other ethnic group/Chinese Chinese or other ethnic group/other Other (please specify) Question Title * 15. In the past week on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? (This may include sport, exercise, and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that is part of your job or school day.) 0 1 2 3 4 5 6 7 Other (please specify) Question Title * 16. I give my consent for my image or video to be used in evaluation and promotional purposes, social media and the YMCA London South West website Yes No Question Title * 17. I confirm to the best of my knowledge that I do not suffer from any medical condition other than those I have specified. Yes No Question Title * 18. I understand that YMCA London South West accepts no responsibility for loss, damage or injury caused by or during attendance on any of the organised activities. Yes No Question Title * 19. If this survey has been completed by a carer/support worker please tell us your name. Done