East London Rape Crisis Counselling

Your community

Professional counselling service for victims of rape by East London Rape Crisis.

East London Rape Crisis provides specialist information and support to all those affected by rape, sexual assault, sexual harassment and all other forms of sexual violence and abuse. Self-referral is required to book an appointment.

Linc Centre

Monday, 9am - 4:30pm

Please contact the centre for more information on 0207 538 5748

Projects Venue Hire Register to use our centres

Community Neighbourhood Centres - Registration form

Personal details

Title *

Mrs

Miss

OtherOther

Name *

Name

First

Last

Address *

Postcode *

Phone *

Email *

Date of birth *

How do you identify your gender? (tick all that apply) *

Male

Female

Non-binary

Transgender

Prefer not to say

OtherOther

Emergency contact details

Name *

Name

First

Last

Phone *

Equalities monitoring

What's your ethnicity? *

White British

White Irish

White other

Indian

Chinese

African

Caribbean

Somali

Bangladeshi

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White & Black Caribbean

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White & Asian

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OtherOther

Do you have a disability or long term health condition? *

Yes

If yes, please select (tick all that apply)

Physical impairment

Sensory impairment

Mental health condition

Long term illness

Learning difference

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OtherOther

Communication consent

There may be times we need to contact you about activities you've registered for and one-off events. This may include using emails to provide updates on new developments at the centres and the use of text messaging to send you reminders, cancellation and activity feedback.

Please select one *

I'm happy for Poplar HARCA community centres to contact me

I do not want Poplar HARCA community centres to contact me

Photo consent

We host lots of events and we often take pictures/videos that are later used in newsletters, reports, our website, publicity articles for press and funding applications amongst other things. If you are happy for us to use your picture please let us know below.

Please select one *

I give consent for my pictures or videos to be used by Poplar HARCA

I do not give consent for my pictures or videos to be used by Poplar HARCA

Data protection statement and agreement

The information that we are collecting on this form will be securely stored in our database so that we can monitor the users at our Community Neighbourhood Centres. Your information will never be passed onto a third party unless we have obtained your prior consent. By submitting this form you are agreeing to us using your information as outlined above.

Tick to acknowledge

How will we use your data?

Information collected on this form will be to register you for activities in our community centres. We collect and process your data with your consent. We also record demographic information to demonstrate that our service is reaching our target audience and that resources are directed to the local community. We will not share your personal information to any third party organisations for marketing purposes. We only share anonymised statistical data with our funders for monitoring purposes. We may share your information with the emergency services in the event of an emergency, All information will be stored securely on our encrypted database. For adults we will store this for 6 years and for children 3 years after your child has turned 18. To find out more about how your information is used by us please read our privacy notice.

Tick to accept

Add a Child?

Add one or more children?

Child Details

Personal details of child/young person

Name *

Name

First

Last

Address *

Same as above

Address

Date of birth *

How do they identify their gender? (tick all that apply) *

Male

Female

Non-binary

Transgender

Prefer not to say

OtherOther

Equalities monitoring of child/young person

What is their ethnicity? *

White British

White Irish

White other

Indian

Chinese

African

Caribbean

Somali

Bangladeshi

Pakistani

White & Black Caribbean

White & Black African

White & Asian

Other mixed background

Prefer not to say

Do they have a disability or a long term health condition? *

Yes

Physical impairment

Sensory impairment

Mental health condition

Long term illness

Learning difference

Prefer not to say

Add another child Remove child

If you are human, leave this field blank.

Contact Us (Community Centres)

Contact our Community Centres using the form below

Name *

First

Email *

Phone *

My comment/query is about: *

Comment *

Data Protection *

I agree to share my data as outlined below

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.

If you are human, leave this field blank.

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