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

* 1. Date

Please enter today's date
/
/

* 2. Contact details

* 3. Gender

* 4. Age

* 5. Do you have a mobility disability?

* 6. Are you pushing a stroller

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

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

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

* 10. How would you rate your health?

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

* 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.

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

* 14. For Office Use Only: Participant Identification Number

Page1 / 1
 
100% of survey complete.

T