Clone of Wellbeing Registration

Forever Active- Wellbeing Registration

Please note that your registration form will be reviewed and you will receive an email to confirm whether you have met the criteria to join the programme. If you have any questions before completing the form please message wilderwellbeing@kentwildlife.org.uk
I understand that any information given by me will be treated as confidential and only be used in relation to my participation in the programme and will be held in accordance with the Data Protection Act 2018 and GDPR 2018.

Kent Wildlife Trust will use your personal data only for the purposes of delivering and managing this programme. Your information will not be sold or shared with any other organisation unless you give explicit permission.

Because this programme is funded by Active Kent and Medway, we are required to share some of your information with them for monitoring and evaluation. Only the minimum data necessary for this purpose will be shared, and it will be handled in accordance with GDPR

For more information on how we handle your data please visit www.kentwildlifetrust.org.uk/privacy-policy

I agree to be contacted by Kent Wildlife Trust e.g. to share information about the programme.

I agree to the information I complete on this form being held by Kent Wildlife Trust.

I am aware that I will be asked to give feedback relating to my wellbeing, as part of the referral process.

I understand that information will be shared with Active Kent and Medway and associated sponsor organisations to evlaatued the Forever Active Kent Grant.

I understand that I will be asked to adhere to policies and procedures by the group leaders. I agree that I will carry out only the tasks that I consider I am fit to do.

Programme
What programme would you like to attend?*
How did you hear about this activtitiy

Your details

We will use these details to contact you about your interest in one our our wellbeing programmes
Name*

First NameLast Name
Phone number*
Email*
example@example.com
Post code *
I am...*
I am aged *
Ethnicity *

Your Heath
Do you consider yourself to have a disability?*
Learning disabilityPhysical disabilitySensory impairmentMental Health conditionLong term health conditionPrefer not to sayOther
Under the following headings please tick the ONE box that best describes your health TODAY
Mobility*
Self Care*
Usual activities e.g. work, housework, family or leisure activities *
Pain/Discomfort*
Anxiety/Depression *
Being Confident - To what extent are you fearful of falling?*
Have you fallen in the last 12 months?*
Is there any other physical or mental health information we should know to help support you while attending the programme (e.g. injuries, recent falls, chronic conditions, anxiety, medication you carry such as an EpiPen, heart conditions such as a pacemaker, sensory needs, or anything else you feel is important)?

Emergency contact details

In case of an emergency who can we contact
Details of your emergency contact*

Name Relationship to you e.g. partner, friend, parent
Emergency contact number *

Photo Consent
Yes, I give consent for photos to be taken of me to be used by Kent Wildlife Trust and Active Kent and Medway.No, please do not use photos of me
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Optional
Thank you for taking the time to complete this form. Please press the submit button to send your details to us.
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Forever Active- Wellbeing Registration

Programme

Your details

Your Heath

Under the following headings please tick the ONE box that best describes your health TODAY

Emergency contact details

Photo Consent

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