CAN - Baseline Registration Form | Chill CIC

"*" indicates required fields

1Name & course details

2Medical

3Swimming

4Changing robe options

5Relationship to the natural environment

6Level of physical activity

7Mental wellbeing

8Individual Development

9CAN Consent

10Chill CIC Consent

11Disclaimer

I am over 55*

Yes

Where is the course taking place*

Please select one

Have you completed a Chill course before?*

These courses are only for people who have not completed a Chill course. If you have completed a Chill course please email jess.foy@chilluk.org for more information

Start date of the course*

Day

Month

Year

Participant name*

First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Participant phone number*

Participant email*

Enter Email Confirm Email

Participant Date of Birth*

Day

Month

Year

What is your sex?*

Emergency contact name

First Last

Emergency contact number*

Which of the following best describes your ethnicity*

White

Mixed

Asian or Asian British

Black or Black British

Other

Please list any medical conditions and or allergies

Do you have any physical or mental health conditions or illnesses that have lasted or are expected to last more than 12 months or more?*

Yes

If yes, do these physical or mental health conditions or illnesses have a substantial effect on your ability to do normal daily activities?*

*IMPORTANT PLEASE READ

Due to the physical nature of the course we do require all participants to be able to swim 50m of a pool unaided and walk approximately 1 mile unaided. At low tide it can be a long walk to and from the water, this is on top of the walk from the car park to the beach which can be rocky depending on the location.

I can swim 50m of a pool unaided*

Yes

Can you walk at least 1 mile unaided?*

Yes

Since you answered no to the last question, unfortunately you do not meet the criteria for this course. Please contact info@chilluk.org for further information

Today’s date*

Day

Month

Year

What or who inspired you?

Any other comments about this course?

Changing robe options

Please choose one of the following

I have access to a waterproof changing robe for the duration of the course?*

Yes

I have access to a robe/dressing gown and a warm jacket to go over the top of it?*

Yes

If you would you like to purchase a long sleeve Moonwrap before the beginning of the course for £87 including delivery, please order below

*You may wish to wait until your place on the course is confirmed before buying your changing robe.

Buy Moonwrap robe

Swim hat options

I have a hat and will put my first name on the hat in large letters so my coach can see it in the water!*

Yes

I need to purchase a CHILL silicone hat costing: £5*

Yes

Buy Chill silicone swim hat

Relationship to the natural environment

Your connection with nature*

	Strongly disagree (1)	Disagree (2)	Mildly Disagree (3)	Neutral (4)	Mildly Agree (5)	Agree (6)	Strongly agree (7)
I always find beauty in nature
I always treat nature with respect
Being in nature makes me very happy
Spending time in nature is very important
I find being in nature really amazing
I feel part of nature

Please rate yourself against each statement by choosing the number that best applies to you, where 1 is Strongly Disagree and 7 is Strongly Agree

Level of physical activity

In the past 7 days, on how many days did you do a walk lasting at least ten minutes?*

No walking

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend walking on each day that you did the activity?*

Was the effort you put into walking usually enough to raise your breathing rate?*

Yes

In the past 7 days, on how many days did you do a cycle ride?*

No cycling

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend cycling on each day that you did the activity?*

Was the effort you put into cycling usually enough to raise your breathing rate?*

Yes

In the past 7 days, on how many days did you do a sport, fitness activity (such as gym or fitness classes), or dance?*

No sport

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend doing sport/fitness on each day that you did the activity?*

Was the effort you put into the sport/fitness usually enough to raise your breathing rate?*

Yes

Mental Wellbeing

Below are some statements about feelings and thoughts. Please rate yourself against each statement by circling the answer that best applies to you for each question.

I’ve been feeling optimistic about the future*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling useful*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling relaxed*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been dealing with problems well*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been thinking clearly*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling close to other people*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been able to make up my own mind about things*

None of the time	Rarely	Some of the time	Often	All of the time

Individual Development

Please rate yourself by choosing the statement that best applies to you

I can achieve most of the goals I set myself?*

Strongly disagree	Disagree	Mildly Disagree	Neutral	Mildly Agree	Agree	Strongly agree

At what age did you leave full time education?

Is this the first time you have completed a CAN registration form?*

Yes

Any other comments about this project?

CAN consent

I have read and I am satisfied that I understand the CAN Data Consent*

Yes

We need to collect some basic information about everyone taking part in CAN projects to ensure that we are reaching and helping the people it is meant to benefit. Your sharing of this information is voluntary, but will be very useful in helping us achieve our objectives. Active Devon only share personal information with the CAN partner delivering and evaluating the project in which you participate, for the sole purpose of supporting your effective and safe participation. Your personal data will only be used in accordance with our privacy notice which you can read at www.activedevon.org/Privacynotice

I agree to allow Active Devon and organisations involved in delivering the CAN project to hold my personal information on the basis stated in the CAN Data Consent*

Yes

I am happy to be contacted by Active Devon with relevant information and opportunities*

Yes

I agree to any photos and video footage of me to be used by Age UK Devon, Active Devon and any CAN partners for promotional purposes*

Yes

I am happy to be contacted with the CAN follow up surveys*

Yes

You will be contacted to complete a simple follow up survey on 3 occasions. This is so we can evaluate the project, understand how it helps you and make it better in the future. The responses are anonymised prior to analysis.

Chill CIC consent

I agree to any photos and video footage of me to be used by Chill and other organisations who are associated with Chill for promotional purposes*

Yes

I agree to allow Chill to hold my personal information for Chill Courses*

Yes

I am happy to be contacted for Chill or their partners for follow up surveys*

Yes

Where did you hear about the course*

Referral from a doctor / social prescriber

Social media

A friend

Search engine

Chill waiting list email

Other

Open Water Swimming Disclaimer

Consent name*

First Last

Consent*

I agree to the Open Water Swimming Disclaimer

The following terms and conditions apply to all swimmers (“you”) attending this open water swim course organised by CHILL THERAPY CIC (“we” or “us”). Please ensure you have read and understand the following.

1. Acceptance of terms and conditions.
By booking or attending a swim session with us, you accept these terms and conditions and they will form part of the contract between us.

2. Sessions.
In order to attend this session you must be able to swim a minimum of 50m freestyle continuously and without rest. You must also be able to tread water easily. If in our opinion you are unable to comply with these minimum requirements then we may cancel your place on the session and if you have already paid for the session we will offer you a credit.

3. Illness, medical conditions and acceptance of risk.
It is your responsibility to ensure that you are medically fit to swim and that at the start of a session you notify us of any relevant medical conditions. If you are showing signs of any Covid19 symptoms, we ask you to not turn up to the lesson. By booking or attending a session with us you confirm to us that:

(a)
You are fit to swim in open water

(b)
You meet the minimum requirements for swimming ability set out in paragraph 2 of these terms and conditions.

(c)
All personal information you have provided to us is correct and not misleading; and

(d)
You understand the dangers of swimming in open water and you agree to swim at your own risk We will not be liable for any accidents or injuries arising from swimming with us, save that nothing in these terms and conditions will limit the liability of any person for death or personal injury caused by negligence.

4. Safety and general rules
Swimmers are responsible for their safety, actions and behaviour on any part of the site property including the changing area. Safety for all is our paramount concern and we have the right to remove anyone on, in or around the site who gives us any concern whatsoever with regard to safety. You enter the water entirely at your own risk and we shall not be liable for any accidents or injuries you sustain. Open water swimming by its nature presents risks to the swimmer over and above those found in a swimming pool and by booking an open water session you accept that you are acting at your own risk and that we shall not be liable for any injury or any other matter suffered by you in the session or as a result of the session (including without limitation for any water borne diseases and/or any injuries caused by wildlife in/on the water.

5. Limitations of Liability
Whilst every reasonable precaution is taken by us to ensure security and safety at our sessions, we shall not in any way be liable for any loss or damage arising in any way from our sessions or venue we use. However, nothing in these terms and conditions shall limit the liability of any person for death or personal injury caused by negligence. Any claim against us arising from attendance at one of our sessions must be notified in writing to us within six months from the day of the relevant session and we shall not be liable for any claim notified to us after this time. In any event, we shall not be liable to you:

(a)
for any purely economic loss, for consequential or indirect losses or for any loss of profit or opportunity;

(b)
(where the claim is insured) for any loss which we are unable to recover from any insurer;

(c)
(where the claim arises as a result of something which was done or not done by a third party) for any loss which we are unable to recover from that third party; and

(d)
for any loss which is greater than the fee paid by you for the relevant session. In the event that you cause harm, damage loss or injury to any other person or property during the session, you agree to indemnify us and reimburse us for all claims, losses, damages, expenses (including reasonable legal fees) and any other liability suffered by us as a result of such harm, damage, loss or injury caused by you. We shall not be liable for any loss or theft of your personal possessions and all property left by you in changing rooms, the car park or anywhere else on or in the vicinity of our venue is done so at your own risk.

6. Governing law
English Law shall govern these terms and conditions and you agree that any disputes shall be resolved exclusively by English courts.

Date of consent*

Day

Month

Year

Signature*

North Devon CAN & Registration form

"*" indicates required fields

1Name & course details

2Medical

3Swimming

4Changing robe options

5Relationship to the natural environment

6Level of physical activity

7Mental wellbeing

8Individual Development

9CAN Consent

10Chill CIC Consent

11Disclaimer

I am over 55*

Yes

Where is the course taking place*

Please select one

Have you completed a Chill course before?*

These courses are only for people who have not completed a Chill course. If you have completed a Chill course please email jess.foy@chilluk.org for more information

Start date of the course*

Day

Month

Year

Participant name*

First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Participant phone number*

Participant email*

Enter Email Confirm Email

Participant Date of Birth*

Day

Month

Year

What is your sex?*

Emergency contact name

First Last

Emergency contact number*

Which of the following best describes your ethnicity*

White

Mixed

Asian or Asian British

Black or Black British

Other

Please list any medical conditions and or allergies

Do you have any physical or mental health conditions or illnesses that have lasted or are expected to last more than 12 months or more?*

Yes

If yes, do these physical or mental health conditions or illnesses have a substantial effect on your ability to do normal daily activities?*

*IMPORTANT PLEASE READ

I can swim 50m of a pool unaided*

Yes

Can you walk at least 1 mile unaided?*

Yes

Since you answered no to the last question, unfortunately you do not meet the criteria for this course. Please contact info@chilluk.org for further information

Today’s date*

Day

Month

Year

What or who inspired you?

Any other comments about this course?

Changing robe options

Please choose one of the following

I have access to a waterproof changing robe for the duration of the course?*

Yes

I have access to a robe/dressing gown and a warm jacket to go over the top of it?*

Yes

If you would you like to purchase a long sleeve Moonwrap before the beginning of the course for £87 including delivery, please order below

*You may wish to wait until your place on the course is confirmed before buying your changing robe.

Buy Moonwrap robe

Swim hat options

I have a hat and will put my first name on the hat in large letters so my coach can see it in the water!*

Yes

I need to purchase a CHILL silicone hat costing: £5*

Yes

Buy Chill silicone swim hat

Relationship to the natural environment

Your connection with nature*

	Strongly disagree (1)	Disagree (2)	Mildly Disagree (3)	Neutral (4)	Mildly Agree (5)	Agree (6)	Strongly agree (7)
I always find beauty in nature
I always treat nature with respect
Being in nature makes me very happy
Spending time in nature is very important
I find being in nature really amazing
I feel part of nature

Please rate yourself against each statement by choosing the number that best applies to you, where 1 is Strongly Disagree and 7 is Strongly Agree

Level of physical activity

In the past 7 days, on how many days did you do a walk lasting at least ten minutes?*

No walking

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend walking on each day that you did the activity?*

Was the effort you put into walking usually enough to raise your breathing rate?*

Yes

In the past 7 days, on how many days did you do a cycle ride?*

No cycling

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend cycling on each day that you did the activity?*

Was the effort you put into cycling usually enough to raise your breathing rate?*

Yes

In the past 7 days, on how many days did you do a sport, fitness activity (such as gym or fitness classes), or dance?*

No sport

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend doing sport/fitness on each day that you did the activity?*

Was the effort you put into the sport/fitness usually enough to raise your breathing rate?*

Yes

Mental Wellbeing

Below are some statements about feelings and thoughts. Please rate yourself against each statement by circling the answer that best applies to you for each question.

I’ve been feeling optimistic about the future*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling useful*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling relaxed*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been dealing with problems well*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been thinking clearly*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling close to other people*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been able to make up my own mind about things*

None of the time	Rarely	Some of the time	Often	All of the time

Individual Development

Please rate yourself by choosing the statement that best applies to you

I can achieve most of the goals I set myself?*

Strongly disagree	Disagree	Mildly Disagree	Neutral	Mildly Agree	Agree	Strongly agree

At what age did you leave full time education?

Is this the first time you have completed a CAN registration form?*

Yes

Any other comments about this project?

CAN consent

I have read and I am satisfied that I understand the CAN Data Consent*

Yes

I agree to allow Active Devon and organisations involved in delivering the CAN project to hold my personal information on the basis stated in the CAN Data Consent*

Yes

I am happy to be contacted by Active Devon with relevant information and opportunities*

Yes

I agree to any photos and video footage of me to be used by Age UK Devon, Active Devon and any CAN partners for promotional purposes*

Yes

I am happy to be contacted with the CAN follow up surveys*

Yes

Chill CIC consent

I agree to any photos and video footage of me to be used by Chill and other organisations who are associated with Chill for promotional purposes*

Yes

I agree to allow Chill to hold my personal information for Chill Courses*

Yes

I am happy to be contacted for Chill or their partners for follow up surveys*

Yes

Where did you hear about the course*

Referral from a doctor / social prescriber

Social media

A friend

Search engine

Chill waiting list email

Other

Open Water Swimming Disclaimer

Consent name*

First Last

Consent*

I agree to the Open Water Swimming Disclaimer

Date of consent*

Day

Month

Year

Signature*

"*" indicates required fields

1Name & course details

2Medical

3Swimming

4Changing robe options

5Relationship to the natural environment

6Level of physical activity

7Mental wellbeing

8Individual Development

9CAN Consent

10Chill CIC Consent

11Disclaimer

I am over 55*

Yes

Where is the course taking place*

Please select one

Have you completed a Chill course before?*

These courses are only for people who have not completed a Chill course. If you have completed a Chill course please email jess.foy@chilluk.org for more information

Start date of the course*

Day

Month

Year

Participant name*

First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Participant phone number*

Participant email*

Enter Email Confirm Email

Participant Date of Birth*

Day

Month

Year

What is your sex?*

Emergency contact name

First Last

Emergency contact number*

Which of the following best describes your ethnicity*

White

Mixed

Asian or Asian British

Black or Black British

Other

Please list any medical conditions and or allergies

Do you have any physical or mental health conditions or illnesses that have lasted or are expected to last more than 12 months or more?*

Yes

If yes, do these physical or mental health conditions or illnesses have a substantial effect on your ability to do normal daily activities?*

*IMPORTANT PLEASE READ

I can swim 50m of a pool unaided*

Yes

Can you walk at least 1 mile unaided?*

Yes

Since you answered no to the last question, unfortunately you do not meet the criteria for this course. Please contact info@chilluk.org for further information

Today’s date*

Day

Month

Year

What or who inspired you?

Any other comments about this course?

Changing robe options

Please choose one of the following

I have access to a waterproof changing robe for the duration of the course?*

Yes

I have access to a robe/dressing gown and a warm jacket to go over the top of it?*

Yes

If you would you like to purchase a long sleeve Moonwrap before the beginning of the course for £87 including delivery, please order below

*You may wish to wait until your place on the course is confirmed before buying your changing robe.

Buy Moonwrap robe

Swim hat options

I have a hat and will put my first name on the hat in large letters so my coach can see it in the water!*

Yes

I need to purchase a CHILL silicone hat costing: £5*

Yes

Buy Chill silicone swim hat

Relationship to the natural environment

Your connection with nature*

	Strongly disagree (1)	Disagree (2)	Mildly Disagree (3)	Neutral (4)	Mildly Agree (5)	Agree (6)	Strongly agree (7)
I always find beauty in nature
I always treat nature with respect
Being in nature makes me very happy
Spending time in nature is very important
I find being in nature really amazing
I feel part of nature

Please rate yourself against each statement by choosing the number that best applies to you, where 1 is Strongly Disagree and 7 is Strongly Agree

Level of physical activity

In the past 7 days, on how many days did you do a walk lasting at least ten minutes?*

No walking

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend walking on each day that you did the activity?*

Was the effort you put into walking usually enough to raise your breathing rate?*

Yes

In the past 7 days, on how many days did you do a cycle ride?*

No cycling

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend cycling on each day that you did the activity?*

Was the effort you put into cycling usually enough to raise your breathing rate?*

Yes

In the past 7 days, on how many days did you do a sport, fitness activity (such as gym or fitness classes), or dance?*

No sport

1 day

2 days

3 days

4 days

5 days

6 days

7 days

How much time did you usually spend doing sport/fitness on each day that you did the activity?*

Was the effort you put into the sport/fitness usually enough to raise your breathing rate?*

Yes

Mental Wellbeing

Below are some statements about feelings and thoughts. Please rate yourself against each statement by circling the answer that best applies to you for each question.

I’ve been feeling optimistic about the future*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling useful*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling relaxed*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been dealing with problems well*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been thinking clearly*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been feeling close to other people*

None of the time	Rarely	Some of the time	Often	All of the time

I’ve been able to make up my own mind about things*

None of the time	Rarely	Some of the time	Often	All of the time

Individual Development

Please rate yourself by choosing the statement that best applies to you

I can achieve most of the goals I set myself?*

Strongly disagree	Disagree	Mildly Disagree	Neutral	Mildly Agree	Agree	Strongly agree

At what age did you leave full time education?

Is this the first time you have completed a CAN registration form?*

Yes

Any other comments about this project?

CAN consent

I have read and I am satisfied that I understand the CAN Data Consent*

Yes

I agree to allow Active Devon and organisations involved in delivering the CAN project to hold my personal information on the basis stated in the CAN Data Consent*

Yes

I am happy to be contacted by Active Devon with relevant information and opportunities*

Yes

I agree to any photos and video footage of me to be used by Age UK Devon, Active Devon and any CAN partners for promotional purposes*

Yes

I am happy to be contacted with the CAN follow up surveys*

Yes

Chill CIC consent

I agree to any photos and video footage of me to be used by Chill and other organisations who are associated with Chill for promotional purposes*

Yes

I agree to allow Chill to hold my personal information for Chill Courses*

Yes

I am happy to be contacted for Chill or their partners for follow up surveys*

Yes

Where did you hear about the course*

Referral from a doctor / social prescriber

Social media

A friend

Search engine

Chill waiting list email

Other

Open Water Swimming Disclaimer

Consent name*

First Last

Consent*

I agree to the Open Water Swimming Disclaimer

Date of consent*

Day

Month

Year

Signature*

CAN – Baseline Registration Form

*IMPORTANT PLEASE READ

Since you answered no to the last question, unfortunately you do not meet the criteria for this course. Please contact info@chilluk.org for further information

Changing robe options

If you would you like to purchase a long sleeve Moonwrap before the beginning of the course for £87 including delivery, please order below

Swim hat options

Relationship to the natural environment

Level of physical activity

Mental Wellbeing

Individual Development

CAN consent

Chill CIC consent

Open Water Swimming Disclaimer

North Devon CAN & Registration form

*IMPORTANT PLEASE READ

Since you answered no to the last question, unfortunately you do not meet the criteria for this course. Please contact info@chilluk.org for further information

Changing robe options

If you would you like to purchase a long sleeve Moonwrap before the beginning of the course for £87 including delivery, please order below

Swim hat options

Relationship to the natural environment

Level of physical activity

Mental Wellbeing

Individual Development

CAN consent

Chill CIC consent

Open Water Swimming Disclaimer

*IMPORTANT PLEASE READ

Since you answered no to the last question, unfortunately you do not meet the criteria for this course. Please contact info@chilluk.org for further information

Changing robe options

If you would you like to purchase a long sleeve Moonwrap before the beginning of the course for £87 including delivery, please order below

Swim hat options

Relationship to the natural environment

Level of physical activity

Mental Wellbeing

Individual Development

CAN consent

Chill CIC consent

Open Water Swimming Disclaimer