School Club Sign Up Form

Child's contact and personal information

Referred by:*

Name:*

Date of birth:*

Gender assigned at birth:*

Address:*

Postcode:*

How would you describe your child’s ethnic origin?*

(e.g. White British, Black/Black British African, Asian/Asian British Pakistani)

GP surgery:*

If you are not registered at GP surgery or are unsure, please type ‘unsure’.

GP name:*

If you are not registered at GP surgery or are unsure, please type ‘unsure’.

Preferred language:*

Do you or your child need an interpreter?*

Yes
No

Guardians contact and personal information

Guardian name:*

Guardian relationship:*

Guardian mobile/telephone number:*

Guardian email:*

Other contact details or information

Other Guardian details, Social worker, etc.

Does your child have any additional/complex needs?*

If no, please type ‘none’.

Consents

I consent to someone from the OneLife Suffolk team contacting me via:*

Telephone
Post
SMS/text message
Voicemail

Can we contact your GP surgery?*

Yes
No

Are you happy for us to contact you in future?*

Yes
No

Are you happy to for us to share your data with Leeds Becket university for research purposes?*

Yes
No

Are you happy for us to speak to any members in your household?*

Yes
No

Are you happy to consent to processing of your personal data? Having read out the statement* shown below:*

Yes
No

In order to attend a healthy lifestyle programme and monitor attendance and outcome data it is necessary to process your personal data to include your name, address, date of birth, contact details and health history. MoreLife will process your personal data as mentioned solely for the purpose of attendance and participation in a healthy lifestyle programme and the monitoring of outcomes. You can request to withdraw or vary your consent by application to the data controller (MoreLife), please see our privacy policy on our website: onelifesuffolk.co.uk/about/privacy-policy

Other Information

What other services would you like support from?

Stop Smoking
Adult Weight Management
Health Walks

How did you hear about us?*

Referral date:*

Child's Health Information

Height:*

Weight:*

Any health conditions:*

If no, please type ‘none’.

Do they take any medication?*

Yes
No

If yes, what medication do they take?

Any other information:

Child's contact and personal information

Guardians contact and personal information

Consents

Other Information

Child's Health Information

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