Social Prescribing Webform South Birmingham Alliance PCN Please enable JavaScript in your browser to complete this form.Please complete the registration form below to access free activity sessions delivered by The Active Wellbeing Society and partners in your local area.GP surgery *Bournville SurgeryFrankley Health CentreKeynell Covert SurgeryKings Norton MedicalLey Hill SurgeryNorthwood & Alvechurch SurgeryCofton Medical PracticePlease select the GP Practice you are registered withNHS Number if knownThis will support with ensuring medical records are accurately updated Your name *FirstLastContact telephone/mobile no: *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 sayGenderMaleFemaleOtherDate 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)Mini kids: Fridays 09:45 - 11:30am Term Time only - (A free, welcoming, stay & play group)Shenley Crafts & Carols - Sunday 18th Dec - 10am-12pm (Free activities for all ages)The Shed - Friends of Cotteridge Park: Roam Playgroup Mondays 10-11.30The Shed - Friends of Cotteridge Park: Mondays GOATS 11am - Getting On At The Shed The Shed - Friends of Cotteridge Park: Mondays - Shed Soup 12.30-2pmThe Shed - Friends of Cotteridge Park: Tuesdays - Gardening Group 10amThe Shed - Friends of Cotteridge Park: Tuesdays Pre-Schoolers Forest School 11.30The Shed - Friends of Cotteridge Park: "Tuesdays - Drawing Group 12pmThe Shed - Friends of Cotteridge Park: "Wednesdays - Knit and Natter 10.30amCotteridge Church Day Centre: Every Monday, Tuesday, Wednesday, Thursday, Friday at 8:30 a.m. for 7 hours - Day Care Service for Older Adults with varying needs including dementia. Activities, refreshments, transport, 3-course meal.The Cotteridge Church Café: Every Monday, Tuesday, Wednesday, Thursday, Friday, Saturday at 10 a.m. for 4 hours - Cafe with snacks and hot lunches. Saplings Stay and Play: Every Friday at 9:30 a.m. for 2 hours - Parent and Toddler Stay and Play Group Fridays term timeBarber Institude of Fine Arts: Our new monthly social prescribing programme builds upon our work within arts, health and wellbeing. This programme will encourage a journey together – looking, responding and creating opportunities to build new connections with art and each other.Physical Activity Interest (multiple choice)The Shed - Friends of Cotteridge Park: Tuesdays - Baby Buggy Stroll 1pmThe Shed - Friends of Cotteridge Park: Social Running Group Tuesdays 6.30pm Exercise on prescription (BActive programme) The Shed - Friends of Cotteridge Park: Wednesdays - Bike Polo 8pm check @brumbikepolo for updatesThe Shed - Friends of Cotteridge Park: Thursdays - Tai Chi 10.30amThe Shed - Friends of Cotteridge Park: Fridays - Walking Group 10.30amThe Shed - Friends of Cotteridge Park: Saturdays - Social Running Group 9.30 The Shed - Friends of Cotteridge Park: Saturdays - SwingFit 10.00amThe Shed - Friends of Cotteridge Park: Sundays -Gardening Volunteers 10.15amMens Keep Fit: Occuring Every Monday at 8 p.m. for 1 hour, 30 minsPat Benson boxing academy (Address: 50 Adderley St, Birmingham B9 4ED) Monday/Thursday (AM) Mind fit sessionsSocial Walk & Coffee: Tuesdays - 1pm-3pm (A moderate paced walk around the park and local surrounding areas followed by an optional coffee and chat at the activity centre.)Active Seniors - Rubery: Active Seniors - Mondays, 12.15pm to 1.15pm Cost: £4.00Yoga in Green Spaces: Thursdays - 10.00-10.50amVirtual 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 internetBefriending/Talking Support ServicesFriendship services At Age UK, one of the ways we try to combat loneliness in later life is through our friendship services.Befriending Service: Through befriending, lunch clubs, assisted shopping, activity and friendship sessions, outings, escorts to appointments and much more, MHA Communities across the UK help to tackle loneliness and isolation in people over 55 – helping them to lead fulfilled lives and remain as active members in their local communities.Communitea Café - Age Concern: 9:00am – 4:00pm | Wednesday to SaturdayCoffee and Chat: Every Thursday at 6 p.m. for 2 hoursCreative Support (Mental Health) Drop In: Every Tuesday at 6 p.m. for 2 hours, 30 minsThe Shed - Friends of Cotteridge Park: Wednesdays - Knit and Natter 10.30am Other Support Services:Dementia Support Worker Appointment (Telephone / Face-to-faceDementia friendly Café Support for CarersBenefit Checks & SupportEmployment Support ServicesVolunteeringTick 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, Our Health Partnership/South Birmingham Alliance 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