Section A: Applicant information

Section B: GP details

Section C: Registration & Wellbeing Card

A wellbeing card will be sent to your address. Use this card to register for free at any of our activity programs.

Section D: What are your top 3 priorities today?

Section E: Pre-Activity Questions

We want to ensure you are safe to take part in activities. Please inform your activity leader of any future changes.

Section F: Lifestyle Health Assessment – Physical Activity

In this section we want to explore how many hours / mins a day you spend active or sedentary.

Section G : Lifestyle Health Assessment – Sleep

Section H : Lifestyle Health Assessment – Nutrition

Section I : Lifestyle Health Assessment – Other

Section J: Happiness Pulse *

We will go through some statements about your feelings and thoughts to help you measure, understand and improve your wellbeing.

Section L: Your goal(s)

Please describe in your own words what you would like to achieve across the next four months.

Section M: Applicant consent

How information about you will be used?
Information you provide is collected and stored securely by 1) Saheli Hub, a company limited by guarantee (No. 8373929) and registered charity (No. 1153202); and 2) The Active Wellbeing Society Limited, a charitable community benefit society (No. 7595) registered with the ICO (No. ZA266982), working in partnership with Birmingham City Council. We and our partners will hold this information in confidence and comply with all our responsibilities under the General Data Protection Regulation and Data Protection Act 2018. For details about our Privacy Policy please visit and

Applicant consent: I have read, understood and completed this form honestly and agree to keep my activity team leader informed of any changes to my health any medical conditions that may impact on my ability to take part in activities. I understand that I participate at my own risk.

Section N: Media Consent

The Active Wellbeing Society and Saheli may wish to use photography, film and/or sound recordings taken of you. These may appear on our printed publications, on video, our website and email imagery. Please sign the declaration below to make this possible.  The Active Wellbeing Society and Saheli will only use recordings appropriately. Your personal data will be processed in accordance with the provisions of the Data Protection Act 2018 and General Data Protection Regulation.

I give my permission for photographs, sound and video footage to be taken for:

Printed publications
Web pages
Promotional videos

You can withdraw your consent at any time – ask us to remove media by contacting us by email or phone (   0121 728 7030). We will remove media and keep you informed when media is removed. The Active Wellbeing Society and Saheli will not use personal details or full names of anyone with media.