Booking Request Form - All Ability Use this form to book a space on the All Ability program.Core Contact InformationName(Required) Email address(Required) Postcode Borough of residence(Required)-- Please Select --NewhamHackneyTower HamletsWaltham ForestKensington and ChelseaWestminsterDate of Birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Health info that may affect training (eg has inhaler pump) GDPR preferencesPhoto consent(Required) Yes No Happy to be contacted in future?(Required) Yes No Consent to participation in BW activities Yes No In Case of Emergency Contact details(Required) How did you hear about Bikeworks? Referral from GP/ Nurse/ Social Prescriber/ Community Connector or similar Referral from other professional e.g Occupational Therapist/ Counsellor or similar From someone or promotional material in my community From an external website or social media (eg council website) Can’t remember/ Don’t know/Other Demographic InformationAge(Required)-- Please Select --Under 1616-2425-3435-4445-5455-6465+Prefer Not to SayGender-- Please Select --Non-binaryGender FluidFemaleMaleOtherPrefer not to sayEthnicity-- Please Select --White: BritishWhite: IrishWhite: Any Other White BackgroundMixed Race: White & Black CaribbeanMixed Race: White & Black AfricanMixed Race: White & AsianMixed Race: Any Other Mixed BackgroundAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: BangladeshiAsian/Asian British: Any Other Asian BackgroundBlack/Black British: CaribbeanBlack/Black British: AfricanBlack/Black British: Any Other Black BackgroundChineseAny Other Ethnic GroupPrefer Not to SayDo you consider yourself to have a disability?-- Please Select --YesNoPrefer Not to SayAdditionally for schoolspupil premium Yes No SEND Yes No Project Specific informationAA:Are you a carer? Yes No Short Breaks allocation? Yes No Δ
