MOVE IT - Referral - Active Lifestyles Sefton

Child's Full Name

First Last

Age*

Gender*

Male
Female
Prefer to self-describe
Prefer not to say

If you selected Prefer to self-describe, please state below

Referred By*

Parent/Guardian full name*

First Last

Address*

Street Address Address Line 2 City ZIP / Postal Code

Parent/Guardian Phone Number*

Parent/Guardian Email

Preferred location*

Type of session – Tick all that apply*

5-6 Years Consultation
1-2-1 Session (7-18 years)
Group Class (11-18 years)
No Preference

Due to high demand we sometimes run group session when there is sufficient interest

Medical Information

Are there any medical conditions, special education needs or disabilities that the Move IT Team need to be made aware of? If Yes please describe below

Yes
No

Medical Information

E.g. Conditions/disabilities such as asthma, diabetes, Attention Deficit Disorder, Downs Syndrome, Behavioural disorders, Autism, Dyspraxia, Dyslexia etc

How did you hear about us?**

If you are a branch of children’s services and would like updates please add your name and email address below

To opt in to these conditions please tick the relevant box.

I give permission to be contacted for additional support by Active Sefton or any other service that your family may benefit from during/post programme to contribute to service evaluation.
I consent to my child having a mini health assessment to include height, weight and waist measurement were possible.

Terms and Conditions*

• By submitting this form I am consenting to being contacted by the Active Lifestyle Team by either:
o Email
o SMS/Phone

Your information will not be used for any other purpose other than what has been requested.

• I understand that I (parent/legal guardian) need to attend each session with my son/daughter/s.

• I understand that if any family member is not well enough to participate he/she must contact the MOVE IT leader, and seek further advice.

• I understand that we are taking part voluntarily in the recommended exercise and the parent/legal guardian is responsible for monitoring any medical conditions including my own condition, as well as making sure any necessary medication (IE inhalers) are available during the activity sessions.

• If using skype I will ensure that we are logged on at the agreed day and time ready for the session which includes appropriate clothing and footwear for exercise.

• The health and safety of individuals is of prime importance to the MOVE IT team and whilst accessing the outdoor area of our leisure facilities I will ensure that my son/daughter behaves in a manner that complies with all regulations. I understand that failure to do so may lead to subsequent retraction of the programme.

• I am aware that if we miss two consecutive sessions without informing the MOVE IT instructor it may lead to subsequent retraction of the programme.

• When accessing the programme from home via Skype I will ensure that the space used for exercise is safe and appropriate with the necessary space to do the activities.

• I will ensure my family and I will only take part in the programme/ exercise activities agreed and devised by the MOVE IT leader.

• We will comply with the Data Protection Act 1998 ensuring your information is secure and retained. Information collected will be used for monitoring and evaluation and as a contact measure for yourself.

• During the 6 week programme I am aware that my son/daughter may have their height and waist taken in order to check their progress. The MOVE IT leader will explain each test and make sure that we understand what it involves. Parent/guardians will need to carry this test out themselves. This is mandatory and you can opt in through the tick box below.

• By submitting this form you confirm that you are the legal guardian for the child named above and you understand that you are voluntarily accessing the programme.

I agree to the Terms and Conditions

Move IT - Self Referral