Allsorts Participant Starter Form Personal Data Name * First Name Last Name Email * Phone * Address Date of Birth MM DD YYYY Disability * Please Choose Learning Disability Other Disability No Disability Prefer not to say Do you have any support or access needs? Please tell us any information we need to know. Please keep us updated if this information changes. Medical Conditions * Please Choose Asthma Diabetes Epilepsy None If not listed, please share Is there any important medical information we should know? Emergency contact name * First Name Last Name Emergency Contact Phone * Key worker name First Name Last Name Key worker phone Key worker organisation Photography We often take photos and film at our sessions and events. By attending you may be included within our photos that we sometimes use on our website, blog and print, like brochures. Are you happy to have your photograph taken? Please Choose Yes No How did you hear about Heart n Soul? Gender Please Choose Male Female Non-binary Prefer not to say Not listed If not listed, please share Ethnicity Please Choose Asian or Asian British – Bangladeshi Asian or Asian British – Chinese Asian or Asian British – Indian Asian or Asian British – Pakistani Asian or Asian British - Other Black or Black British - African Black or Black British - Caribbean Black or Black British - Other Mixed White - British White - Irish White - Other Other Prefer not to say Your Data Thank you very much for filling in the starter form. The information that you’ve given is used for our own records, to make sure that we provide a safe environment. We keep this data securely and only staff who need to know the information have access. Our funders need us to have information on ethnicity, gender and disability. This is used for reports and is used anonymously. No data is given to an unauthorised third party. Please see our privacy policy for more information: www.heartnsoul.co.uk Stay in Touch! If you would like to be updated about what happens at Heart n Soul please tick the box below I would like to be updated about Heart n Soul projects, news, events and fundraising activities. Yes Please! You can remove or update your information at anytime. Thank you, someone will be in touch soon. We look forward to seeing you at Allsorts!If you have any questions, please call Heart n Soul on 020 8694 1632.
