1. 65+ or older (or 45+ for Aboriginal/Torres Strait Islander)
 
Yes
No
 
2. Are you able to walk safely in home without using a walking frame?
 
Yes
No
 
 
3. Live in your own home (ie not in a Residential Aged Care home)
 
Yes
No
 
4. Be able to do light exercise in a group setting
 
Yes
No
 
 
5. Am able to follow instructions and participate in group activities
 
Yes
No
 
6. Can you attend the sessions in English?
 
Yes
No
 
 
 
If no, please mention your preferred language.
 
 
 
Who are you enquiring for?*
 
 
 
Who to contact regarding Enquiry (if applicable)
 
 
 
Potential participant details: 
 
First Name*
 
 
Last Name*
 
 
 
Email
 
 
Mobile*
 
 
 
Participant Post Code*
 
 
 
 
 
 
Referrer details (if applicable) 
 
Referrer First Name
 
 
Referrer Last Name
 
 
 
Referrers Email
 
 
Referrer Mobile
 
 
 
 
 
Alternate friend / family member to contact (only required if potential participant is not the preferred contact) 
 
Friend / Family First Name
 
 
Friend / Family Last Name
 
 
 
Friend / Family Email
 
 
Friend / Family Mobile
 
 
 
1_Random Email
 
 
1_Lead Channel
 
 
How did you hear about us?
 
 
Marketing Campaign
 
 
1_Enquiry Details
 
 
I would like to receive communications such as newsletters, articles, products and services, promotions, discount offers and events from Catholic Healthcare.
 
 
 
 
 
 
 
Business Unit
 
 
Post Code
 
 
1_Reason for enquiry
 
 
I consent to completing this registration form. I understand that I will be contacted by a Catholic Healthcare staff member confirming registration. If I am completing this form on someone else, I declare that they have consented to this registration.