Medical & Fitness Declaration Form

To be returned to:

Rita Eker
The One to One Project
Carradine House
237 Regents Park Road
London
N3 3LF

Your Name (required)

Your Email (required)

Your Age (required)

Your Address (required)

Have you within the last six months:

Run 8 km (5 miles) in less than 50 minutes?
YesNo

Walked 20 km (12 miles) in one stretch?
YesNo

Taken equivalent exercise?
YesNo

If so, please state briefly what the equivalent exercise was

Describe your intended weekly exercise regime: