Arts for Wellbeing Booking/Referral Form

Arts for Wellbeing Booking/Referral Form
Date:*

DayMonthYear
Date
Full Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

TownTown

Post Code
Tel:*
Which workshops would you like to attend?
Arts and Wellbeing Creative Writing Workshops at the Muni Theatre, Colne, Saturdays 1.00 pm until 3.00 pm
Please choose as many sessions as you like.

Please note that spaces are limited and that if you are unable to attend you MUST inform us immediately at email administration@pendleleisuretrust.co.uk. Failure to inform us may result in this free service being withdrawn from you.
Referral/Self Referral Details
GP Name:
GP Practice:
D.O.B:*

DayMonthYear
Date
Email:*
example@example.com
Brief reason for referral/self referral:*
Any disabilities/mobility issues/ physical health conditions: *
Any allergies:*
Is there anything else you would like us to know?
Next of kin
Emergency Contact Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

TownTown

Post Code
Tel:*
Relationship:*
Referrer's contact details:

If self-referred please leave this section blank
Name

First NameLast Name
Tel:
Team / Agency:
Email:
example@example.com
Consent for Photography/Filming
I consent to Pendle Leisure Trust using photographs and/or video recordings of me to promote Pendle Leisure Trust. These images can be used in print and digital media formats, including print publications, websites, e-marketing, posters, banners, advertising film, social media and YouTube.

I understand that images on websites can be viewed throughout the world and not just in the United Kingdom and that some overseas countries may not provide the same level of protection to the rights of individuals as EU/UK legislation provides.

Pendle Leisure Trust will review the use of these images every two years.
YesNo
Signature

Clear
Your Rights:

You have the right to request to see a copy of the information we hold about you and to request corrections or delections of the information that is no longer required. You can ask Pendle Leisure Trust to stop using your images at any time either by emailing gdpr@pendleleisuretrust.co.uk

Images and/or film footage will not be used in future publications but may continue to appear in publications already in circulation.
Pendle Leisure Trust is registered with the Information Commissioner & complies with the Data Protection Act 1998,and revised GDPR (May 2018) ,Reg no PZ5841488.

The Legal Basis for collection of the above Personal Data is: Legitimate Interest.
Should be Empty:

Arts for Wellbeing Booking/Referral Form

Which workshops would you like to attend?

Referral/Self Referral Details

Next of kin

Referrer's contact details:

Consent for Photography/Filming