THF MENS WEIGHT MANAGEMENT PARTICIPANT REFERRAL FORM

SESSION ID

At the Tottenham Hotspur Foundation we want our participants to have an enjoyable and safe experience with us. That's why it's very important for us to have clear and accurate information about people taking part. Please fill in the details below and take time to read the privacy notice and where we are asking for consent.

For participants under 18, this form must be completed by a person with parental responsibility (legal authority) for them.

PRIVACY NOTICE: This privacy notice tells you how we will use your information in line with the law and your rights. We collect personal information from you so that we can give you the services you have signed up for and to make sure that these services are run in a safe, fair and equal manner. We will keep your information secure and will not share data with anyone outside the Foundation unless requested by service providers and unless we are required to do so by law or to prevent abuse or harm. We will keep your personal information for the length of the course and a one year follow up period, after which we will anonymise so you can’t be identified any longer.

If you have any queries please contact us on thf.activities@tottenhamhotspur.com.or 020 8365 5138

Please tick to confirm you have read and understood the privacy notice

PARTICIPANT INFORMATION

FIRST NAME

LAST NAME

DATE OF BIRTH (DD/MM/YYYY)

Address Line 1

Post Code

Home phone number

Mobile

MEDICAL DETAILS

Medication

Will you bring medication to sessions?

Disclaimer: our staff are not qualified to administer medication/Epi-Pen

Access needs

Please confirm your patient is aware of the referral onto the project

The patient is deemed safe and fit to take part in a physical exercise session.

Feedback: If you have any comments or suggestions about our services,

please email us at thf.activities@tottenhamhotspur.com or call us on 020 8365 5138.

By doing this we will be able to continually improve our service.

Safeguarding is Fundamental to the success of all that we do.

Tottenham Hotspur is committed to safeguarding children and adults at risk.

Contact Information