New Customer Registration Form

EMPOWER WALSALL

Registration Form

Thank you for your interest in our MCC sessions. These have been funded by the organisation named above which means we can charge as little as £2.00 per person per group, family sessions are £3.00 per family*. There will be refreshments available, however with Zumba you may want to bring a bottle of water with you. All personal belongings are at the owners own risk.

*Family includes (same address) 1 adult & 2 children, it will be an extra 50p per adult or child.

Activities & Times

BSL course 1 - Friday 27th September for 6 weeks 10am-12pm

BSL course 2 - Friday 8th November for 6 weeks 10am-12pm

Art Every Friday from 27th Sept 1pm-3pm

Zumba Every Saturday from 14th Sept 10.15am-11.00am

Zumba gold/families Every Saturday 11.15am-12.00pm

Crafty Group Every Thursday from 19th Sept 9.30am-11.30am

Family Session - BSL Wednesday 2nd Oct x 5weeks 5pm-7pm

Family Session - Art Wednesday 13th Nov x 5weeks 5pm-7pm

You can join more than one activity

BSL, Art, Crafty and Family Sessions are run from WHG community Centre Dudley Fields (next to Cook's Choice)

Except for Zumba which is run from St Thomas Church Hall, Mossley, Walsall WS3 2UW

All the data submitted below will be treated in accordance to our GDPR / Data Protection policy which is available upon request.

Please name the Group or Groups you would like to attend
Your Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

Street Address Line 3City

Post code
Phone Number*

PrefixNumber
E-mail
example@example.com
I confirm I am over 16 (these sessions are for adults only)*

Yes
How did you hear about us?*
Other (Please Specify)
Please note you will be asked to complete a PARQ (Physical Activity Readiness Questionnaire) at your first session of Zumba.
Covid 19
Please do not attend the session if you are experiencing Covid symptoms or have tested positive for Covid.
Family Sessions
Below can you give the name of each child that would like to join BSL and/or Art if under 16, over 16's to complete their own forms.
Photography and Video

We would like to be able to share photographs and video of the work created on this project across our social media channels. This includes our website, YouTube, FaceBook, LinkedIn, Instagram and Twitter accounts. Photos/videos may also be shared with the funders.
Are you happy to consent to this type of photography and sharing?*

YESNOUnder 16's
Do you have any specific access requirements?

YESNO
If 'yes' please tell us about that here:
Any other information you think we should know eg allergies
OPTIONAL: Are you interested in volunteering with our organisation?

YESNO
Use of your data

All information will be treated as strictly confidential by MCC CIC. High level summaries may be shared with the funders. All data will be collected and stored in accordance with the GDPR 2018 guidelines. Data may be provided to the funders upon an audit or monitoring visit.
Consent
I agree to take part in the activity and for monitoring data to be shared as detailed above.*

YES
Signature*

Clear
Should be Empty:

EMPOWER WALSALL

Covid 19

Family Sessions

Photography and Video

Use of your data

Consent