Self-Referral Online Form



Peer led physical activity programme for older adults.



Children's healthy lifestyle programme supporting your child and family to get active, eat well and achieve a healthier weight.



Referral programme for people affected by cancer, supporting them to increase their physical activity levels and improve their confidence to adopt a healthier, more active lifestyle.



By ticking this box I agree that I understand that submitting an application does not guarantee me a place on the programme.

To the best of my knowledge there is no reason why I should not participate in a personalised activity programme. I understand that I take part in any recommended programme entirely at my own risk and waive any legal recourse for damages arising from my participation and am responsible for monitoring my own responses during physical activity and will inform my Instructor of any new or unusual symptoms or any changes in my medication as soon as possible

I understand that the information I have provided in this form will be kept confidential and will only be used by authorised staff to help me plan and follow my activity programme. Edinburgh Leisure will not share your data with any else except in a medical emergency. We may process data for staistical purposes but all data will remain anonymous.