Move Together

Your Details (the person enquiring on behalf of the participant)

Your first name

*

Your last name

*

Your phone

*

Your email

*

What is your relationship to the participant?

What is your organisation and role?

Do you have the consent of the particpant to fill out this form on their behalf?

*

Yes

No

Before you continue!

You must get the participant's consent to fill out this form on their behalf.

About the participant

Participant's first name

*

Preferred name (if different)

Participant's last name

*

Participant's date of birth

*

Expected format: dd/mm/yyyy

Participant's GP Practice

NHS Number (if known)

Why are you enquiring about Move Together?

Any other relevant information?

About the participant's health

If you do not know the answers to these questions, please leave them blank

Contacting the participant

Participant's phone

*

Alternative phone

Participant's email

Address line 1

*

Address line 2

Address line 3

City/Town

*

Postcode

*

Does the participant need an interpreter?

Yes

No

e.g. an interpreter for foreign language or for BSL/Deaf interpreting

Please give details about the interpretation required:

Does the participant have any other communication difficulties we should be aware of when contacting them?

Yes

No

What communication difficulties should we be aware of?

Is there someone else we should contact instead of the participant?

No

Yes - contact me

Yes - contact someone else

Contact's first name

*

Contact's last name

*

Contact's phone

*

Contact's email

Contact's relationship to the participant

*

When is the best time for us to attempt contact?

e.g. Mon-Wed 9am-1pm

Informed Consent

Before completing this section

You must have gained permission from the Partipant to grant their Informed Consent as outlined in the information below.

The information you provide on this enquiry form will only be used to administer your interest in joining Move Together. The District Council and Active Oxfordshire are the joint data controllers of the information you provide, and are processing this data, contractually, in order to provide this service to you. Move Together will use your information in accordance with UK GDPR and UK DPA 2018.

We will share your information with the District Council who is responsible for providing support and signposting to meet your physical activity needs as part of Move Together. Information that you enter on this form will be sent directly to the Move Together team to contact you and get started. Your data will be collected electronically or on paper and stored safely in a secure database.

The participant gives their consent for their personal information to be used as described in the above notice.

*

The Move Together team would like to contact you to provide advice and guidance to take part in physical activity, including regular follow ups to offer ongoing support.

Please be aware that you have the right at any time to withdraw this consent and to stop us from contacting you. If you would like to do so, please contact your Move Together district coordinator.

The participant gives their consent to be contacted by email, telephone or text message regarding Move Together

*

The personal information you provide will be held for a period of 3 years following your last known contact with Move Together, after which it will be securely destroyed. You have the right to the access and removal of personal data concerning you.

The participant is happy for Move Together to use the information provided as part of the long-term monitoring and evaluation, and to be contacted for monitoring and evaluation purposes

*

Optional Questions

This section of the form is completely optional. Filling it out will help us monitor and improve Move Together.

How did the participant hear about Move Together?

Please tell us where

To which gender identity does the participant most identify?

Please describe their gender

What is the participant's ethnic group?