Activity registration form

Activity Registration From
Age of service user (If this form relates to a child under 18 then a parent/carer MUST fill out this form)
Ethnicity
Registered disabled
Do you have any dependants?
Thinking back over the last 12 months, how would you say that your health has been on the whole, compared to people of your own age?
Do you suffer from depression or anxiety?
Do you have regular access to the internet?
Are you registered with any social group? E.g. tenants association, book clubs
Are there any other activities you would also be interested in?
Data Protection *
When you use forms to get in touch with us, we collect personal information for the purposes of dealing with your enquiry. Our website is developed by Tessellate Design Studio Ltd and they are our data processor. Tessellate Design Studio will only process personal information in line with our instructions. Read their full privacy notice. The information submitted to us may also be stored longer on Poplar HARCA databases for the continuation of services to you. We will not share your information with any third party company unless we have sought your consent or to carry out a legal obligation to you, such as fix a repair. Read our full privacy notice.