Move Together

About you

First name

*

Preferred name (if different)

Last name

*

Date of birth

*

Expected format: dd/mm/yyyy

GP Practice

NHS Number (if known)

Why are you enquiring about Move Together?

Any other relevant information?

About your health

How to contact you

Phone number

*

Alternative phone number

Email

Address line 1

*

Address line 2

Address line 3

City/Town

*

Postcode

*

Do you need an interpreter?

Yes

No

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

Please give details about the interpretation required:

Do you have any other communication difficulties we should be aware of when contacting you?

Yes

No

What communication difficulties should we be aware of?

Is there someone else we should contact instead of you?

No - contact me

Yes - contact someone else

Contact's first name

*

Contact's last name

*

Contact's phone

*

Contact's email

Contact's relationship to you

*

When is the best time for us to attempt contact?

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

Informed Consent

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 the 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.

I give my consent for my 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 the Move Together district coordinator.

I give my 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.

I am happy for Move Together to use the information I have provided as part of the long-term monitoring and evaluation, and to contact me 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 you hear about Move Together?

Please tell us where

To which gender identity do you most identify?

Please describe your gender

What is your ethnic group?