Falls Prevention Course Enquiry Form

Which course suits you?

Participant Name*

First Last

Participant DOB*

What would the participant like to gain from the course?

Contact telephone number*

Who's number is this?*

Address*

Street Address Post Code

Email*

Enter Email Confirm Email

About your mobility

Please describe your mobility as accurate as you can

Please select the option which best describes your mobility*

Can you walk independently...

Indoors
Outdoors
Both

walk independently with a walking aid

Inside
Outside
Both

If any, which walking aids do you use?

Falls

Have you fallen in the last 6 months?

Yes
No

Have you recently developed a fear of falling, even though you have never fallen?

Yes
No

Any other information?

Feel free to make us aware of any other information you think is relevant.

Please give details here.

Payment Information

The cost of the 6-week course is £48.00. Payment is required prior to starting the course. We will send out an invoice by using the details you have submitted. We send invoices via email. If you would like the invoice sending to an alternative address please indicate below.

Email

Falls Prevention Enquiry Form

About your mobility

Falls

Any other information?

Payment Information