	Can you swim? (Are you able to swim from one end of the pool to the other)				*
		Yes No

	Are you a Southwark resident?				*
		Yes No

	How old are you? (Lessons for 16-60s will be at Peckham Pulse only during the 2019 trial but will be available in all centres in 2020).
		Under 16 Between 16 and 60 (FULL) Over 60

	Sub Category

	Do you have a disability?
		Yes No

	Please confirm if you have any of the following disabilities, so we can adapt our service accordingly.
		Hearing (e.g. deaf, partially deaf or hard of hearing) Vision (e.g. blind or partially sighted) Physical/Mobility (e.g. wheelchair user, arthritis, multiple sclerosis, etc.) Mental Health (lasting more than a year e.g. severe depression, schizophrenia, etc.) Learning Difficulties (e.g. dyslexia, dyspraxia, etc.) Memory Problems (e.g. alzheimer's, etc.) Health/Other:

	Does your disability affect you participating in physical activities, such as swimming?
		No Yes, limited a little Yes, limited a lot

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