Medical and Fitness Declaration

To be returned to:

Rita Eker
The One to One Project
Carradine House
237 Regents Park Road
London
N3 3LF
  Section 1 (to be completed by applicant)
your name
your age
your address
  Have you within the last six months:
a. Run 8 km (5 miles) in less than 50 minutes? yes no
b. Walked 20 km (12 miles) in one stretch? yes no
c. Taken equivalent exercise?
(If so, please state briefly what it was) 		yes no

  Describe your intended weekly exercise regime:
 

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