Our Power Hub Registration Form

Our Power Hub Registration Form
Name

First NameLast Name
Gender

MaleFemaleOther
E-mail
Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which ward do you live in? (if known)
Doctor

First NameLast Name
Surgery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact

First NameLast Name
Emergency contact details

Phone numberEmail
Relationship
Do you have any allergies?
Would you like to be included in any pictures or media?
Ethnic Group

White BritishWhite IrishWhite & AsianWhite & Black AfricanWhite & Black CaribbeanMixedBlack AfricanBlack CaribbeanAsianOther
Please specify.
What activity would you like to join?
Please let us know if you have a disability and if you may need assistance or please list anything you feel we should know in the box below.
How often do you usually attend this session?

Every weekMost weeksOccasionallyThis was my first session
Which age group applies?

Under 1818 or over

Is the child eligible for free school meals?

YesNoPrefer not to sayNot applicable
Will you require crèche provision for the Yoga session? (Currently only available for Yoga sessions)*

YesNo
Please tell us the age(s) of your child(ren)
eg. 2 and 5
Health Declaration I confirm that I am physically able to take part in light to moderate exercise. If I have any medical condition or injury that may affect participation, I have consulted a GP or qualified health professional and informed the session lead. I will speak to the trainer about any concerns.*

I understand and agree
Would you like to be added to the OPH WhatsApp group for weekly session updates and booking polls?*

YesNo
This information helps Our Power Hub report anonymously to funders and improve our programmes.
Your personal details are kept securely and are not shared outside the organisation.
Should be Empty: