SOUTHERN BROOKS

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Physical Activity Link Worker Referral Form

You have been invited to work with a Physical Activity Link Worker. Please complete the form below, and one of the team (Diana, Lewis or Clare) will be in touch with you.

We are a busy service, so there may be a wait. Thank you for your patience.

*By completing this referral form, you are consenting to Southern Brooks holding your personal data and special category data (where you choose to give it) for the purposes of processing your referral. Personal data includes your name, age, contact details, access needs and next of kin.

Special Category data includes your beliefs, sexual orientation, ethnicity, disability, employment status, and health conditions.
If you are completing this form on behalf of someone else, you are confirming that the person you are referring has consented to you passing on their data.

For more information about how we process your data, please see the GDPR page on our website or contact Southern Brooks directly on 01174 034238 or office@southernbrooks.org.uk

Physical Activity Link Worker Referral Form
Name
Name
First Name
Last Name
Your gender
Do you have any accessibility needs/disabilities or health conditions that we need to be aware of?
*By completing this referral form, you are consenting to Southern Brooks holding your personal data and special category data (where you choose to give it) for the purposes of processing your referral. Personal data includes your name, age, contact details, access needs and next of kin. Special Category data includes your beliefs, sexual orientation, ethnicity, disability, employment status, and health conditions.
If you are completing this on making this referral on behalf of someone else, please provide:
If you are completing this form on behalf of someone else, you are confirming that the person you are referring has consented to you passing on their data.