Application Form 2018

Please ensure that you read the application form and terms and conditions carefully and complete ALL questions. Please note that the information included on this application form will only be shared with the professionals partnering St Luke’s on this event.

Full Name: ………………………………………………………………………………………………………………

Address: …………………………………………………………………………………………………………………...

………………………………………………………………….. Postcode: …………………………………………….

Email: ……………………………………………………………………………………………………………………...

Telephone: ……………………………………………….. Date of Birth: ………………………………………………

Question 1: What are your reasons for taking part in Mission Slim possible 2018?

Question 2: What do you hope to achieve?

Question 3: What is the hardest thing for you about losing weight and getting fit? Question 4: What barriers can you foresee to your success during this programme?

Questions 5: Do you follow a particular diet e.g. Vegan, vegetarian, gluten free, raw diet, etc..

Question 6: Are you aware of any health reasons – or any other reasons – that might prevent you from doing or increasing the level of your physical activity? YES/NO If yes, please provide details:

Question 7: Have you had any operations in the last five years? YES/NO If yes, please provide details:

Question 8: Do you suffer from back pain? YES/NO

Question 9: Do you have any existing health conditions that will affect your availability to lose weight or exercise? (e.g. diabetes,asthma,epilepsy,bone/joint/back problems/high blood pressure) YES/NO If yes, please provide details:

Question 10: Do you suffer from any allergies or intolerances? (eg wheat, dairy) YES/NO If yes, please provide details:

Question 11: Do you have a heart condition? YES/NO

Question 12: Are you currently taking any prescription medication, including antidepressants? YES/NO. If yes, please provide details:

Question 13: Are you pregnant, or do you have a child under 6 months old? YES/NO

If you have answered YES to any of the above questions, you must provide us with a doctors certificate to confirm that you are fit to take part.

Question 14: How do you plan to raise the require sponsorship (remember we can help by offering you bag packing sessions and volunteering opportunities where the money you raise can go towards your sponsorship)

Question 15: What are your reasons for supporting St Luke’s Hospice? Terms & Conditions (Please read carefully before committing yourself)

I, (please print name) …………………………………………………………………………. confirm that:

 I am over the age of 16 years.   I commit to raising a minimum of £325.00 for St Luke’s Cheshire Hospice.   From Tuesday 23 January I commit to attend every Tuesday group training session.   If I have to withdraw from the competition, the Hospice will use its discretion about payment of sponsorship owing, as it may not be able to fill your place.   I understand that places are limited and filling out this application form does NOT guarantee my place.   I understand that the Hospice has absolute discretion to select participants.   I give my permission for my image to be captured by the Hospice and outside sources. I understand that these images may be used indefinitely to promote the work of St Luke’s (Cheshire) Hospice and its fundraising activities.   I will comply with all instructions given to me by the various trainers and the event organiser. If I do not comply with those instructions or these terms and conditions, the Hospice may at its discretion require that I cease to take part in the training sessions/competition with immediate effect and without compensation to me.   I understand that I am participating at my own risk.    Signed: ………………………………………………………………... Date: ………………………………..    St Luke’s Cheshire Hospice Limited and its subsidiary companies St Luke’s Promotions Limited and St Luke’s Trading Limited are registered under the Data Protection Act 1998. The Hospice does not pass personal data to any other organisations, but may wish to keep you informed of Hospice news and activities.  We would also love to share other relevant information with you about our work, events, news and fundraising activities. We will treat this individual relationship with you with total respect.   Would you like to hear from St Luke’s in the future?   Yes No  Postal Communication [ ] [ ]  Email communication [ ] [ ] Email ……………………………………………………………..  Text messages [ ] [ ] Mobile ……………………………………….………………….  Phone calls [ ] [ ] Home ……………………………….………………………….    Please return your completed form to :  Mission Slim-possible 2018  St Luke’s (Cheshire) Hospice, Grosvenor House, Queensway,  Winsford, Cheshire CW7 1BH  or email it to [email protected]