Active4Health Registration form

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					                                                  Shropshire County
                                                                Primary Care Trust


                                        Application Pack

Shropshire County PCT is looking for exercise providers to join its                    initiative to
help people build activity into a regular part of their lives. As part of this initiative the
            website has been developed to promote and publicise physical activity
opportunities to those most in need of becoming more active.

It is also for anyone wishing to promote exercise classes or other physical activity
opportunities that are particularly suitable for ‘inactive’ people.

            is primarily aimed at people who may have become inactive through ill-health or
age –related conditions or never enjoyed formal exercise or sport.
Those using the               website will be:
    Patients taking part in health programmes at their GP practices, such as Help2Slim, a
      practice nurse-led adult weight management programme currently being delivered in a
      number of GP practices
    Practice nurses and other health professional looking for exercise opportunities to sign
      post their patients too
    Members of the public looking for opportunities to become more active in their local

How does the                   website work?
The                 webpage’s are part of the Shropshire County PCT website. They provide a
range of ideas on how to increase physical activity levels, ranging from building activity into
daily life, or attending a structured exercise class. The “search facility” holds details of all
classes on the                 register.

Patients and public use the website to:
    learn about different types of “start up” exercise
    find some top tips for becoming active in daily life
    find classes that meet needs and interests by using the built in “search facility” on the
    gain reassurance that the type of activity they choose is welcome and supportive

How do Exercise Providers benefit?
Being placed on the          register offers you the chance to:
    support people to become active
      promote your exercise class to a new audience
      attract new members
      increase your income

The details submitted by exercise providers are provided to the public through the
“search facility”.

Being part of the            has other benefits:
    become part of a health initiative supporting active lifestyles
    gain recognition for providing activities aimed at supporting inactive people to become
      more active for health benefits
    Access to the               logo for promotional material

All exercise providers who are placed on the               register are entitled to free use of
the                logo to promote registered classes. This can be used on associated printed
material, such as posters or fliers.
The details submitted by exercise providers are provided to the public through the
“search facility”.
Registration and website listing is free. Being part of            has no implications for the
fees charged for the exercise class; exercise providers do not receive a subsidy and therefore
remain free to set the costs of attending their own classes.
To view the search facility directly visit:

How to join?
Any exercise teacher working in Shropshire meeting the quality assurance standards for their
discipline can apply to be placed on the          register, providing the following are met:
      have appropriate current professional indemnity, public liability and premises insurance
      deliver classes in line with the relevant professional body or NGB best practice guidance
      use a PARQ ( physical activity readiness questionnaire) with all new members
      use venues where an appropriate risk assessment has been undertaken
      have procedures in place in case of emergencies
      provide accurate detailed updates regarding any changes to provision

You also need to describe your class, particularly what makes it suitable and welcoming in a
way that is reassuring and encouraging and there is a top tips guide to help you do this.

If you are unsure whether or not your class is appropriate for            please use the
             self-assessment tool to help you decide.

For a copy of this simple self-assessment tool please call or email:
01743 277526

                                Registration Form
Please complete in full:
Section 1

 Date         /      /

 Exercise tutor or lead contact name ……


 Post Code

 Contact number

 e-mail address

 Important information for all prospective               exercise tutors
 The information you provide in section 2 of this registration pack will be included within the
              WebPages. Please ensure all information given is true, accurate and helpful to those
 using the site to search for physical activity opportunities. By returning a completed signed and
 dated application pack you are agreeing for details submitted to become publically available.
 The PCT retains editorial control of any content published on the website; any text submitted may
 be altered in line with content guidance.

 Return completed application pack to:
 Michael Parry
 Shropshire County PCT
 Public Health Department
 William Farr House
 Mytton Oak road
 SY3 8XL

 Section 2
 Please complete the table below using the space provided to give a short explanation as to
 what your qualification enables you to teach and to whom.

Relevant Exercise Related
              &                                 Explanation of your Qualification
  First Aid Qualifications

Please confirm the following:

Do you have:                                                          Yes

Professional indemnity, public liability & premises insurance cover

Agreed emergency procedure in place

A venue risk assessment

All               exercise providers must follow good practice. Please confirm the following: by
using the following for any exercise classes.

Do you use:
Physical Activity Readiness Questionnaire (PAR-Q)

Attendance register

If you require information about or would like a PAR-Q (Physical Activity Readiness
Questionnaire) please contact Mike Parry on 01743 277526.

                                        Class Registration Form
(If you wish to register more than one class forms may be photocopied, submit separate forms for each class)

  1. Name of Class
  2. Name of Tutor
  3. Venue
  4. Premises insurance cover             Yes       N/A
  5. Time of class                          Day             Length of Session
  6. Cost per person £              (Discounted? If so provide details)….
  7. How can people find out if your class has spaces available?

  The activity description box below gives you an opportunity to promote your class to an
  unlimited audience actively seeking to change their exercise habits. The information you
  include in this free text box should help the individual who is likely to be sedentary, develop
  understanding and motivate them to make an informed decision about the suitability of the
  class for them.

  People using                  may have a limited understanding of what it is an exercise class has
  to offer them and be unaware what is expected from participation. They may lack confidence,
  be apprehensive and anxious about exercising. Please use the                           Top Tips guide to
  describe your Activity in simple, clear, friendly and encouraging language.
  You may also wish to include some of the information used in the self assessment bench mark
  criteria to describe your activity.

    Activity Description (Please use no more than 100 words)

                                   Declaration Form
By signing this declaration you are verifying a commitment to work to best practice and
confirming all information supplied is correct and accurate.

I/We of _ _ _

   1) Certify that all information submitted in support of this registration is correct and that
      the aforementioned organisation has suitable insurance arrangements covering both
      exercise provider and participant

   2) Certify that the premises and equipment of the aforementioned organisation comply
      with the Health and Safety Executive Regulations, and comply with insurance

   3) Agree to operate within the terms of good practice set out by Governing Bodies and

   4) Agree to update Shropshire County PCT                   of any changes to the registered
      class or developments affecting my registration

   5) Agree to maintain regular annual contact with the                     team, providing
      information as required: including information upon numbers of participants and those
      signposted via the              webpage or Help2slim

   6) Agree to respect patient confidentiality at all times

   7) Agree to work only with those suitable to participate in activity



Office Use Only

Date received         /      /

Date approved         /      /



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