FitConnect Membership Referral

About you

Thank you for joining our Exercise Referral Scheme. FitConnect is all about helping you feel better through movement, connection, and support. The following questions will help us understand your goals, preferences, and any support you might need to get started. Your answers will help us create a personalised and positive experience for you.

Firstly, we need some details that will help us get your membership activated.

First name

Last name

Date of birth

Gender

FemaleMalePrefer not to say

Phone number

Email address

Current home address

Student number

Course

Wellbeing and motivation

What is your main reason for joining the scheme?

Please describe further

How do you currently feel about physical activity?

Very positiveNeutralAnxious or unsureNegative

Wellbeing and motivation

What is your main reason for joining the scheme?

Please describe further

How do you currently feel about physical activity?

Very positiveNeutralAnxious or unsureNegative

Physical Activity history

Have you been regularly active in the past 6 months?

Yes, regularly (1 or more times a week)Occasionally (Less than 4 times per month)Rarely (Less than once per month)Not at all

What types of activity have you enjoyed before?

Health and accessibility

Do you have any health conditions we should be aware of?

Yes – physical healthYes – mental healthYes – bothNo

Do you have any accessibility needs?

Yes – physical accessYes – sensory needsYes – social/emotional supportNo

Support Preferences

How would you prefer to be supported during your FitConnect membership?

Regular check-insPeer support or buddy systemDigital resources or appMinimal support – I’m self-motivated

Why we are collecting your data

The information you provide in this form will be used to activate your FitConnect membership at Ravelin Sports Centre and to help tailor support for you.

By joining the scheme, your data will also contribute to the evaluation of this pilot collaboration at the University of Portsmouth between Student Wellbeing and Sport and Recreation, with the aim of improving the scheme.

Please read the following documents and ensure you agree to the terms before proceeding. All data will be handled in line with university data protection policies.

Please read and agree to the terms of the Health Commitment Statement, Terms and Conditions and Rules and regulations.

I have read and agree to the terms

Please read and agree to the terms of the Privacy Policy.

I have read and agree to the privacy policy

I understand my particpation is as part of a pilot scheme and I am required to provide feedback during and after the pilot finishes.

I understand and am happy to participate