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Roller Ski
£750,00
monthly
Test Swim
Date
Amount
Jan 1,
£750,00
Feb 1,
£750,00
Mar 1,
£750,00
Apr 1,
£750,00
May 1,
£750,00
Jun 1,
£750,00
Jul 1,
£750,00
Aug 1,
£750,00
Sep 1,
£750,00
Oct 1,
£750,00
Nov 1,
£750,00
Dec 1,
£750,00
First name
Last name
Address line 1
Postcode
City
Mobile
Email
Birthday
Any medical needs we should be aware of while you are cycling with us? (e.g. epilepsy, asthma, allergies etc).
1
2
3
4
In the past week, on how many days have you done a total of 30 minutes or more of physical activity (this can include sport, gardening, walking, cycling or any activity that was enough to raise your heart rate)?
yes
no
Prefer not to say
Is this person classed as being on low income ?
Name Of Support Worker
Physical impairment
Intellectual impairment
No impairment
Visual impairment
Hearing impairment
How would you best describe your disability ?
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