Community Care Hall Green PCN: Long-term Health Support Please enable JavaScript in your browser to complete this form.These sessions will be delivered at Sparkhill Leisure CentreThis programme is for individuals within the community who have a long-term health condition (such as diabetes). You will be able to participate in weekly exercise such as Chair Based Exercise, Zumba and sophrology, tailored for all abilities, in a fun and friendly environment. There are limited numbers of FitBits to giveaway too!The Active Wellbeing Society works closely with organisations in the community to reach individuals far and wide. You will have been sent the link to this webform by your GP Practice. You will be contacted in due course by somebody with the full details of these sessions. Select your age group: *18 - 49 years50 years and overPlease select the GP surgery you are registered at: *Hall Green Health CentreSwanswell Medical CentreNorthbrook Health CentreYour title: *MrMrsMsMissOtherOther title - please state:Your Name *FirstLastContact telephone/mobile number: *Email AddressAddress Line 1CityState / Province / RegionPostal CodeDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity *White BritishWhite IrishWhite PolishWhite otherAsian BangladeshAsian IndianAsian PakistaniAsian ChineseAsian otherBlack AfricanBlack CaribbeanBlack otherMixed Asian & BlackMixed Asian & WhiteMixed Black & WhiteAny other ethnicityRather not sayDo you have a disability *YesNoDo you have any medical condition that the instructor would need to know about? *YesNoIf yes, please state the medical condition(s) here:Emergency Contact Person (Name):Emergency Contact Person's Number:Select the sessions you are interested in:Men's Chair Based Exercise - Chair Zumba Women's Chair Based Exercise - Chair Zumba Women's Sophrology - Relaxation, Mindfulness, Breathing etc Thank you for completing the form, you'll be contacted in due course with further information in relation to these sessions. Please note, any level of abilities are welcome - no experience required and all equipment will be provided.Tick to confirm *I agree to register for a Wellbeing CardThe Wellbeing Card is required to enable you to access the free activities through The Active Wellbeing Society. You will be issued with a membership card known as Wellbeing Card which you will receive in the post.Tick to confirm *You will be contacted by a social prescribing link worker via email-SMS with your chosen support services information. Your information request will be updated on to your medical records – if you give consent please tick the boxTick to confirm *I agree to the data protection policy of The Active Wellbeing Society. To view this policy please review below:Privacy Notice How information about you will be used Information you provide is collected and stored securely by The Active Wellbeing Society Limited (community benefit society registered with the ICO; Reg. No. ZA266982), who provide services on behalf of Birmingham City Council, Sport England, Our Health Partnership (Community Care Hall Green PCN). We collect this information to enable us to administer the membership we hold with you, to provide better services, to promote public health and physical activity and monitor the effectiveness of our programmes, to maintain our accounts and records, to prevent fraud and misuse of public funds and to report to our funders. We will keep this information during the time of your involvement with our services and for a period of 3 years afterwards. We may share anonymous information about you with our partner organisations and funders, in order to provide you with appropriate services, to monitor outcomes related to physical activity and healthy lifestyles and to facilitate research and insight. We and our partners will hold this information in confidence and comply with all our responsibilities under the General Data Protection Regulation and Data Protection Act. By signing up, you agree to these terms. You have a right to withdraw your consent at any time at any time by contacting us on 0121 728 7030 or emailing [email protected]. If you would like a copy of our Data Protection Policy please visit http://www.theaws.org/privacy-notice Alternatively, you can find out more about your rights or complain to the Information Commissioner’s Office at ico.org.uk.Submit