MOVE IT - Referral - Active Lifestyles Sefton

Move IT - Self Referral

MOVE IT is a healthy lifestyle programme for children aged 5-18 and their families who need help with weight maintenance.

Child's Full Name*
First Last
Date of birth*
Gender*
- Male
- Female
- Prefer to self-describe
- Prefer not to say
If you selected Prefer to self-describe, please state below
Weight (kg) of participant*
This is needed to ensure the this programme is the correct one for the participant
Height (cm) of participant*
This is needed to ensure the this programme is the correct one for the participant
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*
Would the young person be open to joining a group class? (Age 7+)*
If our waiting list is high there may be the option to run invite only group classes
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?**
Referrer Details
Referred By*
Referrer Name*
Referrer Email Address*
Referrer Telephone*
Reason for Referral*
To opt in to these conditions please tick the relevant box.
- Parent/Guardian gives 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
- Parent/Guardian consents to the child having a mini health assessment to include height, weight and waist measurement
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Terms and Conditions*
- I agree to the Terms and Conditions

Move IT - Self Referral

Referrer Details