MEMBERSHIP REGISTRATION FORM

MEMBERSHIP REGISTRATION FORM

Please complete all details
Full Name*

First NameLast Name
Email*
example@example.com
Home Telephone Number
Please enter a valid phone number.
Mobile Telephone Number*
Please enter a valid phone number.
Gender*

MaleFemalePrefer Not To SayOther
Other, please specify
Age Group*

Under 1818-2930-3940-4950-5960-6970+
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a disability?*

YesNoPrefer not to say
Do you have any access requirements?*

YesNo
Details
Before undertaking any physical activities at Fitzrovia Community Centre, our instructors will require you to provide details of your current state of health and sign a declaration. You do not need to provide details of any health conditions unless it means you will need extra support.
Do you have any physical or mental health condition that we need to know about?*

YesNoPrefer not to say
If yes, please state:
ETHNIC GROUP

(please choose the option which most closely relates to you)
Ethnic Group*

Asian/Asian BritishBlack/Black BritishMixed/Multiple ethnic groupsWhiteOther ethnic group
White

English/Welsh/Scottish/Northern Irish/BritishIrishGypsy or Irish TravellerEastern EuropeanWestern EuropeanAny other White background, please describe
Mixed/Multiple ethnic groups

White and AsianWhite and Black AfricanWhite and Black CaribbeanAny other Mixed/Multiple ethnic background, please describe
Black/Black British

AfricanCaribbeanAny other Black/Black British background, please describe
Asian/Asian British

ChineseBangladeshiIndianPakistaniAny other Asian background, please describe
Other Ethnic Group

ArabAny other ethnic group, please describe
Any other ethnic group, please describe
EMERGENCY CONTACT DETAILS
Name

First NameLast Name
Relationship
Contact Telephone Number
Please enter a valid phone number.
ARE YOU CURRENTLY IN RECEIPT OF ANY OF THE FOLLOWING MEANS-TESTED BENEFITS?

We ask this question to assess whether you are eligible for any concessionary rates. We may ask you to show proof of benefits for certain classes.
Please select all that apply

Universal CreditJob Seeker’s Allowanace (JSA)Working Tax CreditEmployment and Support Allowance (ESA)Housing BenefitFree School MealsStatutory Sick Pay (SSP)State Pension
HOW DID YOU HEAR ABOUT US AND OUR ACTIVITIES?
How did you hear about us?*

Friend/Word of mouthInternet searchNewsletterSocial mediaHealth visitorSocial workerOther, please specify
If Other please specify
Would you like to join our mailing list?

Stay up-to-date with Fitzrovia Community Centre news and activities.
Yes, subscribe me
Mailing list consent*

YesNo
Please select the topics you are interested in hearing about:*

Arts, Culture & HeritageChildren & FamiliesHealth & WellbeingSeniors’ ServicesWomen-only activitiesMen-only activitiesSport & physical exerciseMental wellbeingEmployment & trainingAdvice (e.g. benefits or legal advice)Cooking/healthy eatingCommunity caféEnvironment & sustainabilityNeighbourhood forums/residents’ groupsBusiness supportSupport groupsVolunteeringRoom hire
PHOTO CONSENT

Photos help Fitzrovia Community Centre to attract new members to our wide variety of activities, as well as secure funds for future work.
Do you give permission for us to use photos of you/your children in our promotional materials and/or website?*

YesNo
If you do not give permission, please do also mention it to any photographers when they are taking photographs at our activities and events.
DATA PROTECTION STATEMENT

I understand that FITZROVIA COMMUNITY CENTRE will record this information in a database for the purpose of delivering better services, creating statistics to support funding applications and evaluations, and supporting the creation and delivery of relevant marketing materials to our service users. The database will only be available to other parties if technical and organisational security measures are needed to safeguard this information. In an emergency, the information may also be used to contact a person I nominated to inform them of an incident. FITZROVIA COMMUNITY CENTRE will not disclose my individual personal information to third parties without first seeking my consent, and I am allowed to request to see my data and have it deleted at any time. My information will be treated confidentially.
I have read and understand the data protection statement*

Yes
Signature

Clear
Registered Charity Number: 1104135 Company Registration Number: 4755140
Should be Empty:

MEMBERSHIP REGISTRATION FORM

ETHNIC GROUP

EMERGENCY CONTACT DETAILS

ARE YOU CURRENTLY IN RECEIPT OF ANY OF THE FOLLOWING MEANS-TESTED BENEFITS?

HOW DID YOU HEAR ABOUT US AND OUR ACTIVITIES?

Would you like to join our mailing list?

PHOTO CONSENT

DATA PROTECTION STATEMENT