Come along on Wednesday

Fill this in and I'll be in touch to sort the details. It takes a couple of minutes, and the health questions are the standard ones every class has to ask.

Nothing is charged through this form. If you're taking the twelve weeks I'll send you my bank details to transfer the £75, and your plan follows once it's in. Drop ins just pay cash on the night.

Leave this empty:

About you

Full name Email Mobile Date of birth

Under 18s need a parent or guardian to fill this in with them.

Postcode (optional)

What you're after

You can change your mind later.

Twelve sessions, £75Any Wednesday to the end of December, with your own twelve-week plan. Drop in, £7Just come along and see. No plan included.

In case of emergency

Emergency contact name Their number Their relationship to you

Health

Answering yes to any of these doesn't stop you joining. It just means we have a quick chat first so I can adapt things for you.

1. Has a doctor ever said you have a heart condition, or that you should only do physical activity recommended by a doctor?

Yes No

2. Do you feel pain in your chest when you do physical activity?

Yes No

3. In the past month, have you had chest pain when you were not doing physical activity?

Yes No

4. Do you lose your balance because of dizziness, or do you ever lose consciousness?

Yes No

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes No

6. Is your doctor currently prescribing medication for your blood pressure or a heart condition?

Yes No

7. Are you pregnant, or have you given birth in the last six months?

Yes No

8. Do you know of any other reason why you shouldn't do physical activity?

Yes No

If you answered yes to any of those, tell me a bit more Anything else I should know?

For your plan

Skip this if you're only dropping in.

What are you hoping to get out of it? How active are you at the moment? Anything you can't or won't do?

Before you send

Your health details are only used to keep you safe in class and to write your plan. They aren't shared with anyone and are deleted two years after you last attend. Ask any time to see, correct or delete what's held.

Rather just talk? Email holistichealthcoachdev@gmail.com or call 07927 452055.