Register to attend a Stepping On program in your local area

Stepping On is a free falls prevention program for NSW adults aged 65 years and over, and Aboriginal adults aged 45 years and over, who have had a fall or are fearful of falling.

This registration form must be completed by the participant, or with the participant. Before you complete the registration form, please make sure you have your GP's contact details and your emergency contact details available.

Register for a Stepping On program

Are you of Aboriginal or Torres Strait Islander background?

Date of birth

Have you had a fall in the last year? A fall is a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.

Are you concerned about falling?

Do you walk independently? Walking independently means that you do not use a walking stick, walking frame or any other walking aid to assist you.

Can you walk safely inside your house without using a walking frame?

Do you have any cognitive impairments that may limit your ability to follow instructions and/or participate in group activities? For example, Dementia, Parkinson's Disease or Stroke.

Are you able to do exercise and participate in a group setting?

Do you live in the community? (not in a nursing home)

Do you already attend a weekly exercise program (excluding walking groups)?

Have you attended Stepping On in the last three years?

Are you registering on behalf of someone else?

What is your name?

What is your relationship to the person you are registering on behalf of?

Please state:

First name

Surname

Address

Suburb

State

Postcode

Local Government Area

Contact phone

Alternate phone

Gender

What is the highest level of education you have attained

Are you a carer? A carer is any individual who provides care and support to a family member or friend who is unwell, lives with a disability, mental illness, alcohol or drug dependency, chronic condition, terminal illness or who is frail due to age.

Do you speak a language at home other than English?

Which Language?

Can you attend an English-speaking group?

Are you interested in attending a virtual Stepping On group? Virtual Stepping On is delivered online, using free videoconferencing software (e.g. Zoom).

Emergency contact name

Emergency contact phone

Emergency contact relationship? For example, husband, wife, son, daughter.

General practitioner name

General practitioner address

General practitioner phone

RESEARCH PARTICIPATION - NSW Health is interested to know if this program is helpful to program participants, and understand ways the program could be improved in the future. A researcher may contact program participants once the program is complete. Do you agree for your contact details to be passed onto the researcher? If you are completing this form on behalf of someone else, do they agree for their contact details to be shared?

How did you hear about the course?

If Other, please specify?

I consent to completing this registration form and being placed on the Stepping On waiting list. I understand that I will be contacted by NSW Health when a Stepping On program is available. If I am completing this form on behalf of someone else, I declare that they have consented to this registration.

Unfortunately Stepping On is not suitable for you. This program is for NSW adults aged 65 years or over, or NSW Aboriginal people aged 45 years and over.

Please review the NSW Active and Healthy website to find a suitable exercise program in your local area. You may also like to register for the Get Healthy Information and Coaching Service to receive free health coaching.

Unfortunately Stepping On is not suitable for you. Please review the NSW Active and Healthy website to find a suitable exercise program in your local area. You may also like to register for the Get Healthy Information and Coaching Service to receive free health coaching.

Medical Clearance Required

You are able to join the program however you require a medical clearance from your GP.