Student Membership — Shropshire Shufflers

Family Lead Details

Please enter the membership number of the existing club member who will be responsible for you at training sessions.

Family Lead membership number *

Please enter the membership number of the existing club member who will be responsible for you.

Personal Details

Title *

First name (preferred) *

Surname *

Gender *

Date of birth *

Contact Details

Email address (optional)

Only needed if the student wants their own copy of club emails.

Mobile number (optional)

Physical Activity Readiness Questionnaire

Please answer the following questions honestly. If you answer yes to any question, please speak with your doctor before participating in any new physical activity.

Has a doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

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

Do you ever have chest pain when not doing physical exercise?

Have you ever felt faint or had spells of dizziness?

Do you have any joint or bone problems that could be made worse by any change in your physical activity?

Have you ever suffered from high blood pressure?

Are you currently on any medication that could affect your health by a change in physical activity?

Are you pregnant or have you had a baby in the last 6 months?

Are you over 69 years of age?

None of the above apply to me

I have ticked an option above and will speak with my doctor before participating

In Case of Emergency

Emergency contact name *

Their phone number *

Their relationship to you

Responsible Adult at Training

Please name the adult who will accompany you at club training sessions. This is separate from your emergency contact.

Responsible adult name *

Consent

I consent to my data being used for club administration purposes in accordance with the privacy policy