SP Webform – Sports & Physical Activity for individuals with disability Please enable JavaScript in your browser to complete this form.The Social Prescribing Link Worker based at your surgery would like to offer you social /physical and educational support services to access. The Active Wellbeing Society, delivers a wide range of free activities and support services for adults in partnership with your GP practice. Your social prescribing link worker team are looking to understand some of the challenges and barriers to accessing Sport and Physical Activity for individuals with a disability. From this learning we hope to identify actions that will make it easier for you to take part in and enjoy physical activity in your local community. Please complete the form below by selecting the areas you are interested in. GP surgery *Poolway Medical Iridium Medical Sheldon Medical The Swan MedicalGarretts Green SurgeryNone of the aboveName *FirstLastContact telephone/mobile 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/YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is your disability?ADHDAUTISMDYSLEXIAASD CEREBRAL PALSYDEVELOPMENT DELAY,DOWNS SYNDROMEPHYSICAL DISABILITYOTHER Please state what other disability: *What is your current activity level? *I don't do any exerciseLess than 30 mins per weekMore than 30 mins per weekAre there any barriers stopping you from doing more activity? *TimeCostTransportHealth condition(s)Self confidence/Self esteemNot aware of what is available locallyNot enough opportunity locallyAccessibility of venues at local sessionsNot enough support at the sessionsOtherWhat would make it easier for you to access physical activity sessions? *Sessions more local to meDifferent choice of activities More activities for me to accessCoaches/ Session Leaders who understand my disabilityBetter promotion of sessions in my local areaOtherWhat type of activity is appealing to you?Activity that I can do on my ownActivity that I can do with others/in a teamActivity that improves my strengthActivity that improves my coordinationActivity that improves my flexibilityWhich activities would you like to participate in your local community?PhysicalBocciaCurlingWheelchair BasketballWalking GroupsRunning GroupsLearn to rideCyclingChair Based ExerciseBuddy Group ActivitiesGardeningDanceOtherWhat virtual activities would you like to participate in? YogaZumbaChair Based ExerciseRelaxation SessionsTai ChiWhich social/educational activities would you like to participate in?Arts & CraftsKnit & NatterCoffee Morning - Social ActivitiesMindful SessionLife SkillsEnglish - Basic LiteracyBasic Sign Language Classes (Duration 6 weeks)What other support services would you like to access?Food Pantry -In the local communityHousing & Benefits supportListen and connect: (provides a telephone support service that offers a safe space for people to feel heard)Voluntary Work (The Active Wellbeing society-TAWS)Employment- Mencap/Disability Resource CentreTick 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 (Via The Active Wellbeing Society) 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