Health Swim Online Form

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High Street, Hampton, Middlesex, TW12 2ST

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Health Swim Online Form

Before completing this form, please ensure you have joined Hampton Pool as either a member or non member.

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Member ID number(Required)

(We need this to be able to complete your health swim application

Address

Street Address Address Line 2 Town County Postcode

Email(Required)

Telephone

Date of Birth

Gender Identification

Your Fitness

On a daily basis over the past two months, how happy do you feel on a scale of 1-10(Required)

(1 being the lowest and 10 being the happiest)

On a daily basis over the past two months, how much if at all does anxiety impact your wellbeing on a scale of 1-10(Required)

(1 being the lowest and 10 being the highest anxiety impacts your wellbeing)

In the past seven days, on how many days have you done a total of 30m or more of physical activity that was intense enough to raise your breathing rate(Required)

Of those seven days, how many days did you complete over 60m of activity?(Required)

A little more….

Have you visited Hampton Pool before(Required)

Yes

Yes but not often due to financial responsibilities

No due to financial responsibilities

Other

Please leave us any further information you feel would be helpful for the team.