Group class enrolment Your Details First Name Last Name Email Address Phone Number Gender Gender female male don't know prefer not to say Age Select your age Under 20 20-39 40-59 60-70 70-80 80+ Ethnicity Select your ethnicity New Zealand European Maori Samoan Cook Island Maori Tongan Niuean Chinese Indian Other Other (Please state) Street Address Address Line 2 Suburb City Region Select the region nearest to you Auckland Bay of Plenty Canterbury Hawkes Bay Manawatu Marlborough Nelson Northland Otago Southland Taranaki Waikato Wellington If you know the clinic name where you want to go for these classes, add it here. Otherwise leave blank. Please tick the box of the group class types. (if applicable) Next Steps PaddleOn Online Targeted Class Your Diagnosis Type of cancer Select your diagnosis Breast Bowel Blood Gynae Prostate GI Cancer Kidney Lung Bone Sarcoma Head and Neck Skin Testicular Other If you have Ovarian Cancer please tick this box Please tick the box of any cancer treatment you have received. (if applicable) Hormone therapy Chemotherapy Radiation therapy Surgery Please indicate what exercise category you fit into Select your exercise category Non-exerciser Exerciser before diagnosis Keen exerciser Please tick here if you are happy to receive newsletters and communication from Pinc & Steel in the future. You may unsubscribe at any time. You must enable JavaScript to submit this form
