Registration Form- Participant

AquaZone All-Abilities Gym Program

Thank you for your interest in the AquaZone All-Abilities Gym Program.

Please complete the survey below to register your interest. We will be in contact regarding the availability of places in the program and potential start dates.

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* 1. Name

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* 2. Email

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* 3. Phone

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* 4. Residential address

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* 5. What gender do you identify as?

Female

Male

Non-binary

Prefer not to say

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* 6. What is your age?

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* 7. Do you identify as having a physical disability, which you would describe as 'non- progressive', meaning it does not change over time?

Yes

Not sure- would like to discuss further

Please add any further information/comments

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* 8. Do you have a current AquaZone Gym Membership?

Yes

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* 9. Do you currently have a physiotherapist or exercise physiologist that you see on a regular basis?

Yes

If yes- could you please list the name of the clinic or service where the Physio or Exercise Physiologists is based?. Note- We are planning to circulate a flyer to these clinics, to provide information about the program and gym equipment available. The purpose of this question is to ensure we have all local clinics listed.

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* 10. How would you prefer to receive communications regarding this program?

Mobile text message

Phone call

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* 11. Do you have any questions regarding participation in the program?

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* 12. How did you hear about the program?

Thank you for registering your interest. We will contact you via your preferred communication method to confirm your eligibility and discuss further details of the program.

Privacy Notice- The personal information requested is being collected by Warrnambool City Council for the purpose of administering the AquaZone All-Abilities Gym Program. The personal information will not be disclosed to any other external party unless permitted under the Information Privacy Principles. If you wish to alter any of the personal information you have supplied to Warrnambool City Council, please contact Council via telephone 5559 4800 or email contact@warrnambool.vic.gov.au