Please answer the questions honestly. Your responses are completely confidential.

Date

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* 1. Date

Please enter today's date
Contact details

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* 2. Contact details

Gender

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* 3. Gender

Age

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* 4. Age

Do you have a mobility disability?

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* 5. Do you have a mobility disability?

Are you pushing a stroller

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* 6. Are you pushing a stroller

Are you from an Aboriginal or Torres Strait Island background?

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* 7. Are you from an Aboriginal or Torres Strait Island background?

Do you currently do any physical activity such as walking (including gardening) every week?

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* 8. Do you currently do any physical activity such as walking (including gardening) every week?

Would you like to increase your weekly physical activity level?

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* 9. Would you like to increase your weekly physical activity level?

How would you rate your health?

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* 10. How would you rate your health?

What brought you to the 5 x 5 event?
You may select more than one response

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* 11. What brought you to the 5 x 5 event?
You may select more than one response

How did you hear about the 5 x 5 event?
You may select more than one response

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* 12. How did you hear about the 5 x 5 event?
You may select more than one response

Photos and videos may be taken during the event for Healthy Cities Illawarra and partner's social media and advertising purposes.
Please indicate if you DO NOT want to be photographed or videoed during the event

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* 13. Please indicate if you DO NOT want to be photographed or videoed during the event

For Office Use Only: Participant Identification Number

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* 14. For Office Use Only: Participant Identification Number

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