City of York Council Sport and Active Leisure Teams Disability Sport and Physical Activity Survey 2013

If you have a physical and/or sensory impairment or disability, we would like to know more about what sports and leisure activities you would like to do. Q1. Please tick all the things you would like to do, or do more of, irrespective of your disability or impairment. Ask someone to help if you need to.

Sport / Leisure Activities

Bowls Boccia Cycling Hand Cycling Golf Volleyball Seated Volleyball Badminton Dance Tennis Hockey Wheelchair Basketball Basketball Ten Pin Bowling
Equestrian/Horse Riding 1

Football Power Chair Football Climbing Snooker / Pool Gym Goalball Gymnastics Rebound therapy Trampolining Table Cricket Cricket Archery Netball Rugby League Walking

Swimming Hydrotherapy New Age Kurling Judo Movement to Music Boxing (Non-contact) Fitness Training

Yoga Athletics Table Tennis Polybat Lots of sports at one club

Q2. Please list any other Sports that you would like to take part in that are not on this list:

We would like to know more about you.

Q3. When would you like to do these activities / sports? Mornings Evenings Afternoons Weekends

Q4. What day(s) would suit you best? Monday Friday Tuesday Saturday 2 Wednesday Sunday Thursday

Q5. Which age band do you fit into? Under 16 26 49 16 - 25 50 69 70+

Q6. How would you best describe your impairment?

Physical disability Visual Impairment

Wheelchair user Hearing Impairment

Q7. Do you attend a School / College / University / Day Service / support group/organisation? If yes please list

Q8. Is there anything else you can tell us about yourself that would help us deliver a better service for you?

Using and sharing your information We would like to store your contact details so that we can update you on disability sport and physical activity opportunities in York. If this is something that you consent to, please complete the information below, including email address. Name: ........................................... Address: ...................... Email address: . Telephone number: . Signature: . When you have completed this form, please return FREE to: Jason White Sport and Active Leisure FREEPOST, RTEG-TYYU-KLTXZ City of York Council West Offices Station Rise York YO1 6GA 4

Or email to: jason.white@york.gov.uk Please return this document BEFORE 2nd August 2013