Please complete all required fields!
Thank you for your request to join the Health, Lifestyle, Action Programme.
Please ensure all required fields are completed before submitting the form.
Gender Variant/ Non- Conforming
Not Listed - please specify below
Prefer Not to Answer
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Asian or Asian British
Any other Asian background
Black or Black British
Any other Black background
Other Ethnic Groups
Any other ethnic group – please specify below
Not stated – please specify below
North - Eastcote Health Centre
Central - Civic Centre, Uxbridge
South - The High Street Practice, Yiewsley Health Centre
Type 1 Diabetes Melitus
Type 2 Diabetes Melitus
Other- please state below
I confirm that I am 16 years old or over, with the ability to exercise and do not use mobility aids.
I am willing to commit to the full 12 week programme