Adult Swimming Programme – Application Form (18+)

This programme is designed to support adults who face barriers to being physically active.
Please complete this form so we can check eligibility in line with Sport England guidance.

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Section 1: Personal Details

Full name

Date of Birth Enter as DD/MM/YYYY. You must be 18 or over to apply.

You must be 18 years or older to apply for this programme.

Gender

Female Male Prefer not to say

Contact number

Section 2: Address

Address line 1

Address line 2 (optional)

Town / City

County (optional)

Postcode UK format (we’ll format when you leave the field). Example: SW1A 1AA

Section 3: Eligibility Criteria

Do you currently face any of the following barriers to physical activity? (Tick all that apply)

Long-term health condition Mental health challenges Recovery from illness or treatment Disability or mobility challenges Low income / financial barriers Low confidence or anxiety

Other (please specify) If you tick “Other”, please add details.

None

Please select at least one barrier (this programme is for people who currently face barriers to being active).

You selected “None”. This programme is for adults who currently face barriers to physical activity, so you are not eligible to apply via this form.

How active are you currently?

Not active at all Light activity only Some activity but not regularly Active regularly

Section 4: Health & Wellbeing

Does swimming support your health or wellbeing needs? (Tick all that apply)

Physical health Mental wellbeing Recovery / rehabilitation Stress or anxiety management

Have you taken part in organised physical activity before?

Yes No

Section 5: Motivation

Why would you like to take part in this swimming programme?

What do you hope to gain from swimming? (Tick all that apply)

Better physical health Improved mental wellbeing Confidence Social connection Learning a new skill

Section 6: Consent

Do you agree that your anonymised feedback may be used for monitoring and reporting to Sport England?

Yes No

You selected “No”. We can’t accept applications unless you consent to anonymised monitoring/reporting for Sport England.

Do you confirm that the information provided is accurate?

Please answer the consent question to enable submission.