Section 3:Medical Details and Medication
(For Exercise Buddy Programmes only, or under 18s)

Registration Form

Motivated Minds (Wellbeing 4 life CIC) keeps information of our customers in order to meet our legal obligations and to keep individuals safe when participating in our activities. This form will be kept digitally for three years on completion of our service(s). If you would like a copy of our GDPR policy please ask a member of the team.

Section 1: Personal Details

Age Category

Section 2: Emergency Contact Details
(For Exercise Buddy Programmes only, or under 18s)

Contact One:

Contact Two:

Section 3: Medical Details & Medication
(if deemed necessary to support you)

Section 4: Programme Joining

Section 5: Reason(s) for joining us
(used for data analysis on our services & population requirements )

First of all, welcome and thank you for joining us. Just for our records could you please indicate one or more reasons for joining Motivated Minds? Please tick all that are relevant.


“To the world you may be one person, but to one person you may be the world.”

- Dr. Seuss

01268 520 785 /

HAPPY Hub, Eastgate Shopping Centre, Basildon, Essex, England.

Motivated Minds Trading as Wellbeing 4 Life CIC. Company No.: 9423090 © 2020  

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