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Move Momentum Classes - Book a FREE TRIAL
Class
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Which of our classes are you booking a free trial for?
GEMS (over 65s) - The Arc on Mondays 10:00 - 11:00am
GEMS (over 65s) - Winnall on Tuesdays 10:00am - 11:00am
GEMS (over 65s) - Weeke on Thursdays 10:00am - 11:00am
Liberate Online (wheelchair - 14+) - Wednesdays 7:00pm - 8:00pm
Liberate Youth (wheelchair 7-13s) - Saturdays 12:30pm -1:30pm
Liberate Young Adult (wheelchair 14-21s)
Liberate Adult (wheelchair 21+) - Saturdays 3:30pm - 4:30pm
Email
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Mobile phone number
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Please provide the best phone number to contact you on. If under 18 this should be a phone number for parent/guardian.
Participant First Name
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Participant Surname
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Participant Pronouns
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Is there any information we need to know about you/the participant?
Any medical issues we need to be aware of should be listed here.
Parent First Name
Parent Last Name
Additional Emergency Contact
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Where did you hear about us?
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Google
Facebook
Instagram
Poster/Flyer
Friend/Family/Colleague
GP/Social Prescriber
Winchester Radio
Other please specify below:
Focus group
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We will contact you in the next few days to confirm the date for your FREE trial class.
I accept that by completing this form that I am voluntarily giving permission for myself/my child to take part in Move Momentum’s classes and events. I acknowledge that there is an element of risk involved when taking part in physical activity and whilst strict precautions have been taken by Move Momentum, including by staff, freelancers and volunteers, that sometimes injuries or damage to assets may occur. I am fully aware of the risks that are involved with the activity and assume all risks and hazards incidental to the conduct of the activity. Considering this I hereby waive any claims against Move Momentum and voluntarily ask for permission for myself/my child to participate. I promise to make the instructors aware of any injuries or conditions which may affect myself/my child’s participation in the activity. In the unlikely event of illness or accident, I give permission for any appropriate first aid to be given by the nominated first aider. In an emergency, and if the emergency contact cannot be contacted, I am willing for myself/my child to be given hospital treatment, including anaesthetic if necessary. I understand that every effort will be made to contact the emergency contact as soon as possible.
All data collected will be stored in compliance with GDPR laws, for information on how we use, and store data please see our privacy and data protection policy made available on our website.
Declaration
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