Adult's - START TO WALK
 Registration Form		  

Personal Info ADULT
     
Family Name *
First Name *
Date of Birth *
Gender Male Female *
Nationality *
Picture Upload
     


Contact Info
     
Address *
P.O Box *
City *
Mobile Number *
Home Telephone Number *
Office Number *
Office Email *
Personal Email (1) *
Personal Email (2) *
     

Medical Info Please indicate if any health problems, physical disability or other concerns :
Heart problem  
  Chest pains during exercising
  Do you have a low or high blood pressure ?  
  Do you have a bone, back or muscular problem that may be aggravated by exercise ?  
Do you suffer from asthma or allergies ?  
  Do you suffer from diabetes ?
  Are you pregnant or have you given birth in the past 3 months ?  
If any other, please mention here
* If any of the above questions have been answered positively please provide a doctoral certificate that you are fit to exercise.

Walking Experiences  
Please indicate the level that fits best your profile :
 
  From the couch to the toilet and back! (Beginner)
  And I would walk 500 miles (Advanced Walker)
     

Emergency Contacts  
     
Family Name *
First Name *
Mobile Number *
Office Number
Home Telephone Number *
     

Source It would be great if you tell us of how you knew about us
     
Choose one *
If others, please mention here

 

Personal Info ADULT 2
     
Family Name *
First Name *
Date of Birth *
Gender Male Female *
Nationality *
Picture Upload
     


Contact Info  
     
Address *
P.O Box *
City *
Mobile Number *
Home Telephone Number *
Office Number *
Office Email *
Personal Email (1) *
Personal Email (2) *
     

Medical Info Please indicate if any health problems, physical disability or other concerns :
Heart problem  
  Chest pains during exercising
  Do you have a low or high blood pressure ?  
  Do you have a bone, back or muscular problem that may be aggravated by exercise ?  
Do you suffer from asthma or allergies ?  
  Do you suffer from diabetes ?  
  Are you pregnant or have you given birth in the past 3 months ?  
If any other, please mention here
* If any of the above questions have been answered positively please provide a doctoral certificate that you are fit to exercise.
   

Running Experiences  
Please indicate the level that fits best your profile :
 
  From the couch to the toilet and back! (Beginner)
  And I would walk 500 miles (Advanced Walker)
     

 

Personal Info ADULT 3
     
Family Name *
First Name *
Date of Birth *
Gender Male Female *
Nationality *
Picture Upload
     


Contact Info  
     
Address *
P.O Box *
City *
Mobile Number *
Home Telephone Number *
Office Number *
Office Email *
Personal Email (1) *
Personal Email (2) *
     

Medical Info Please indicate if any health problems, physical disability or other concerns :
Heart problem  
  Chest pains during exercising
  Do you have a low or high blood pressure ?  
  Do you have a bone, back or muscular problem that may be aggravated by exercise ?  
  Do you suffer from asthma or allergies ?  
  Do you suffer from diabetes ?  
  Are you pregnant or have you given birth in the past 3 months ?  
If any other, please mention here
* If any of the above questions have been answered positively please provide a doctoral certificate that you are fit to exercise.
   

Running Experiences  
Please indicate the level that fits best your profile :
 
  From the couch to the toilet and back! (Beginner)
And I would walk 500 miles (Advanced Walker)
     

 

Personal Info ADULT 4
     
Family Name *
First Name *
Date of Birth *
Gender Male Female *
Nationality *
Picture Upload
     


Contact Info  
     
Address *
P.O Box *
City *
Mobile Number *
Home Telephone Number *
Office Number *
Office Email *
Personal Email (1) *
Personal Email (2) *
     

Medical Info Please indicate if any health problems, physical disability or other concerns :
Heart problem
  Chest pains during exercising  
  Do you have a low or high blood pressure ?  
  Do you have a bone, back or muscular problem that may be aggravated by exercise ?  
  Do you suffer from asthma or allergies ?  
  Do you suffer from diabetes ?  
Are you pregnant or have you given birth in the past 3 months ?  
If any other, please mention here
* If any of the above questions have been answered positively please provide a doctoral certificate that you are fit to exercise.
   

Running Experiences  
Please indicate the level that fits best your profile :
 
  From the couch to the toilet and back! (Beginner)
  And I would walk 500 miles (Advanced Walker)
     

 

Personal Info ADULT 5
     
Family Name *
First Name *
Date of Birth *
Gender Male Female *
Nationality *
Picture Upload
     


Contact Info  
     
Address *
P.O Box *
City *
Mobile Number *
Home Telephone Number *
Office Number *
Office Email *
Personal Email (1) *
Personal Email (2) *
     

Medical Info Please indicate if any health problems, physical disability or other concerns :
Heart problem
  Chest pains during exercising 
  Do you have a low or high blood pressure ?  
Do you have a bone, back or muscular problem that may be aggravated by exercise ?  
  Do you suffer from asthma or allergies ?  
Do you suffer from diabetes ?  
  Are you pregnant or have you given birth in the past 3 months ?  
If any other, please mention here
* If any of the above questions have been answered positively please provide a doctoral certificate that you are fit to exercise.
   

Running Experiences  
Please indicate the level that fits best your profile :
 
  From the couch to the toilet and back! (Beginner)
  And I would walk 500 miles (Advanced Walker)
     

* Required fields