Social Prescribing Webform – Poolway medical practice Please enable JavaScript in your browser to complete this form.Complete the registration form below to access free activity sessions delivered by The Active Wellbeing Society and partners in your local area.GP surgery *Poolway Medical CentreName *FirstLastContact Number *EmailAddress *Address Line 1CityState / Province / RegionPostal CodeEthnicity *White BritishWhite IrishWhite PolishWhite otherAsian BangladeshAsian IndianAsian PakistaniAsian ChineseAsian otherBlack AfricanBlack CaribbeanBlack otherMixed Asian & BlackMixed Asian & WhiteMixed Black & WhiteAny other ethnicityRather not sayDate of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have a disabilityYesNoEmergency Contact nameEmergency contact numberOverall, how satisfied are you with your life nowadays? Selected Value: 0 Use the slider to select on a scale 0-10Overall, to what extent do you feel that the things you do in your life are worthwhile? Selected Value: 0 Use the slider to select on a scale 0-10Overall, how happy did you feel yesterday? Selected Value: 0 Use the slider to select on a scale 0-10Overall, how anxious did you feel yesterday? Selected Value: 0 On a scale where 0 is “not at all anxious” and 10 is “completely anxious”, Social Activity Interest (multiple choice)Managing Stress - Topics Change WeeklySocial activity group- Tea/coffee art and craft. (Poolway Medical Practice 1:15-2:15pm.Physical Activity Interest (multiple choice)Walk and Talk- Poolway medical practice (Tuesdays 12-1pm)Green Fingers Group (gardening) Exercise on prescription (BActive programme) Buggy Fit Bike on prescription. (Eligibility based on post code).Chair Based Exercise- At Iridium Medical practice - Fridays 1:30-2:30pmPat Benson boxing academy (Address: 50 Adderley St, Birmingham B9 4ED) Monday/Thursday (AM) Mind fit sessionsVirtual Activity Interest (multiple choice) The active wellbeing society -Virtual sessions Visit: https://theaws.co.uk/virtual/Chair Based ExerciseRelaxation (delivery by Beat It Percussion) Thursdays 7.30pm (Will need email & access to devices.) ALL these activities will take place online and you will need access to internetSocial support needed - select all that apply Food supportEmployment SupportSocial isolation – befriending Finance and Benefits AdviceTick to confirm *I agree to register for a Wellbeing CardThe Wellbeing Card is required to enable you to access the free activities. 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 contact by your 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 box- .Tick 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, or Bordesley East 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