Gym Possible Membership Application Form

 

1. As a charity we were set up to support people with spinal cord injuries. We do occasionally accept applications from people who do not have spinal cord injuries, but if we do not contact you, please do not be offended, our space is very limited. If we think that you will be a good fit for the future, we will contact you when availability opens up. *

 

2. First Name *

 

3. Surname *

 

4. Contact Telephone Number *

 

5. Contact Email Address *

 

6. Do you have a spinal cord injury?

If "No", move on to Question 8 *

 

7. What level of spinal cord injury are you?

e.g. T12 etc.

 

8. When did you sustain your spinal cord injury?

e.g. five years ago

 

9. Other than a spinal cord injury, do you have any conditions that would make you a good candidate for this gym?

Please describe in as much detail as possible, including any associated dates of injury/condition. *

 

10. What Gym Possible services do you hope to use?

Tick all that apply. *

 

11. What are your fitness goals? *

 

12. Who would you be coming to the gym with?

 

13. Do you have any cognitive/intellectual impairments?

If "Yes", please give details below. *

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