5 Swims for a Fiver Registration Form

Go Active Get Healthy is a programme funded by the Oxfordshire Clinical Commissioning group and offers support for those with type 1 or type 2 diabetes to get more active, and in doing so, help manage their condition. Please fill in as much of the form below as you can and we will contact you to arrange your 5 swims for £5 voucher. 5 swims can be used at Barton, Ferry or the Leys Fusion Leisure centre when purchasing your voucher.

More information on the programme can be found at https://www.getoxfordshireactive.org/go-active-get-healthy-oxford-cit

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* 1. What centre would you like to redeem your 5 swims for a fiver voucher at?

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* 2. What is your Name?

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* 3. Are you...

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* 4. How old are you?

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* 5. What is your phone number?

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* 6. What is your email address?

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* 7. What is your postcode?

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* 8. What is your ethnicity?

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* 9. 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 and break out in a sweat? (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 may be part of your job)

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* 10. Which of the following conditions apply to you?

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* 11. Disclaimer. Please tick the box below to confirm that...

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* 12. For participants with one or more of the conditions listed in question 9. Please tick below to confirm that...

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* 13. We would like to be able to send you details of activities that might be of interest to you and information about our GO Active, Get Healthy programme which offers motivational support and advice to help you become more active.  GO Active and Oxford City Council will also use your information for monitoring and evaluation in accordance with the General Data Protection Regulations 2018.

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* 14. In order to register your 5 swims for a fiver voucher at your local leisure centre we will need to share your contact details with a relevant Fusion Lifestyle instructor. Please tick here to confirm you are happy for your contact details to be shared with a relevant Fusion Lifestyle Instructor.

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