First Name Last Name Email Mobile Number Address line 1 Address line 2 Town/City Eircode County Would you like to sign up to our mailing list to receive news and information about upcoming walks? Yes No Date of Birth Gender Male Female I identify in a different way I prefer not to say Next of Kin - Name Next of Kin - Phone Number Which group is nearest to you? Clogheen Clonmel Ardfinnan West Tipperary West Waterford Aherlow Slieveardagh MBL (Moycarkey, Borris, Littleton) Carrick-on-Suir Ballina None of the above Do you have WhatsApp installed on your phone? Yes No Has a doctor ever said you have a heart condition? Yes No Do you ever lose balance because of dizziness or ever lose consciousness? Yes No Do you feel pain in your chest when you do physical activity? Yes No In the past month, have you had pain in your chest when you were not doing physical activity? Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No Do you know of any reason why you should not do physical activity? Yes No I understand that by answering 'Yes' to any of the above questions that I should consult my G.P. before taking part in this walk or walking program. I agree to tell the walk leader if there is any change in my medical condition. I understand to wear appropriate clothing and footwear. I understand that I walk at my own risk. Yes Send
