Possible Fields for Inclusion in Online Registration Form for Physical Activity Providers

Web-Based Directory of Community Physical Activity Falls Prevention Programs

REGISTRATION FORM

Please complete a separate form for each Program

Program Contact Details

Program Name:………………………………………………………………………………….

Program Street Address:……………………………………………………………………….

City/Suburb/Town/Community:…………………………….….Postcode:…………………..

Program Postal Address:………………………………………………………………………

City/Suburb/Town/Community:…………………………….….Postcode:…………………..

Program Phone: ( )…………….………….....Fax: ( ) ……………………….…………..

Program Email (if applicable):.………………………………………………………………...

Program Website Address (if applicable): www.…………………………………………….

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This form can be completed online by visiting www.activeandhealthy.nsw.gov.au/register Page 1 Personal Contact Details

Details provided in this ‘Personal Contact Details’ section are confidential and will not be included in the web-based directory. Please provide these details so we can contact you if necessary.

Contact Name:…………………………………………………….…………………………….

Contact Phone Number: ……………………………………………………………………….

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

Once the web-based directory has been established and your registration has been accepted, you will be able to access and update your information online as required (using a password). Paper-based update forms will be provided if you prefer.

Please indicate your preferred password:……………………………………………………

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Program Details

1. How would you describe your program (please provide brief details, for example ballroom dancing)?

Falls prevention……………………….. Tai Chi or Qi Gong…………………...

Yoga or pilates…………………………. Dance………………………………….

Gentle exercise………………………… Other…………………………………..

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2. What are the key components of the program (please tick all relevant boxes)?

Balance/coordination training Gait/walking training and/or mobility

Flexibility and stretching Strength and resistance training

General physical activity Other (please specify)………………

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This form can be completed online by visiting www.activeandhealthy.nsw.gov.au/register Page 2 3. Which specific balance and strength exercises are included in the Program (examples are available in the Frequently Asked Questions resource provided with this form)?

…………………………………………………………………………………………………….

What is the combined time spent on these exercises in each session? Minutes

What is the total duration of each session? Minutes

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4. Please provide information about the program for inclusion in the Web-Based Directory (50 words or less) (for example “Sun style of Tai Chi. Group-based for up to 20 participants per class”):

…………………………………………………………………………………………………….

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5. Is the time with the exercise leader/program provider centre-based or home- based?

Centre-based Home-based

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6. Is the Program primarily one-on-one or group-based?

One-on-One Group-Based

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This form can be completed online by visiting www.activeandhealthy.nsw.gov.au/register Page 3 7. Is the program individually tailored for each participant?

Yes No

Details (if applicable)……………………………………………………………………………

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8. Are participants encouraged to continue at home in their own time (in addition to the activities undertaken with the program leader/exercise instructor)?

Yes No

If so, for how long?

……..……………………. per week (please indicate minutes/hours per week)

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9. What is the availability of the program?

Available all year round

Available during other specified times only (please specify)…………………………

……………………………………………………………………………………………...

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10. What is the recommended duration of the program for individual participants?

……..… weeks (please indicate number of weeks) OR Ongoing

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11. What is the level of experience required by the program participants?

Beginner (no experience, have not previously attended exercise classes)

Intermediate (limited experience, limited previous attendance at exercises classes)

Extensive (many years of attending exercise classes)

------This form can be completed online by visiting www.activeandhealthy.nsw.gov.au/register Page 4 12. What is the background of the program leader/s (please tick all relevant boxes)?

Nurse Physiotherapist

Tai Chi Leader Occupational Therapist

Sports Teacher Exercise Physiologist

Registered AHS Physical Activity Volunteer

Fitness Leader – please specify Cert 4, Accredited or Registered………………….

Other (please specify)…………………………………………………………………….

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13. What is the target age of the program participants?

Over 50 Over 65

Over 75 Other (please specify)………………

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14. What are your target groups? Please specify. (examples may include the general population, or those with osteoporosis, a diagnosed gait and/or balance impairment or a visual impairment) …………………………………………………………………………………………………….

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15. Are there any participants who would not be suitable for the program? Please specify. (examples may include dementia/cognitive impairment, post-surgery or those with walking aids) …………………………………………………………………………………………………….

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16. Do you have any other special requirements/conditions? (examples may include participants should wear long pants for floor work, or participants should bring their own mat/towel) …………………………………………………………………………………………………….

------This form can be completed online by visiting www.activeandhealthy.nsw.gov.au/register Page 5 17. Do you require participants to obtain clearance from their GP or other healthcare professional prior to commencement of the Program?

Yes (please specify)……......

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18. In-Centre Class Times (start and finish):

Example: Monday: 8.00am – 9.00am, 10.30am – 11.00am, 4.30pm – 5.00pm Tuesday: 10.00am – 11.00am, 6.00pm – 7.00pm etc

Monday:…………………………………………………………………………………………..

Tuesday:………………………………………………………………………………………….

Wednesday:……………………………………………………………………………………...

Thursday:…………………………………………………………………………………………

Friday:…………………………………………………………………………………………….

Saturday:…………………………………………………………………………………………

Sunday:…………………………………………………………………………………………..

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19. What is the cost of the program?

Cost per class/visit………………………………………………………………………..

Cost per term/program…………………Duration of term/program:………………….

By donation

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20. Do private health insurance rebates apply to the program?

Yes No

------This form can be completed online by visiting www.activeandhealthy.nsw.gov.au/register Page 6 Transport Details

21. Is parking available at/near your venue?

Yes No

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22. What type of transport is available to get to your venue?

Bus Train

Community Transport Ferry

None Other (please specify)………………

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23. Would you like to provide any special directions? (examples may include use rear access door or parking readily available in John Street, or head east 500m from Jane Street bus stop):

…………………………………………………………………………………………………….

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Consent

I hereby consent to the inclusion of all information contained within this registration form in the Web-Based Directory of Community Falls Prevention Programs (with the exception of those details provided in the ‘Personal Contact Details’ section).

Name:…………………………………………………………………………………………….

Position:………………………………………………………………………………………….

Signature:…………………………………………Date:……………………………………….

Please return this form to: Project Officer, NSW Falls Program, Locked Mail Bag 812, Coffs Harbour 2450 or via fax to 02 6656 7018

This form can be completed online by visiting www.activeandhealthy.nsw.gov.au/register Page 7