Young Tower Hamlets
Identity
Forename
Surname
Date Of Birth
Gender
Please choose a value
Male
Female
Not Recorded
Demographic
Ethnicity
Please choose a value
Mixed other
Black British
Asian Bangladeshi
Black African
White British
Asian Indian
Mixed White and Black Caribbean
Black Caribbean
Asian Pakistani
Other
Refused to say
Black Other
Mixed White and Black Asian
White Other
Mixed White and Black African
White Irish
Asian British
Prefer Not To Say
White Traveller of Irish Heritage
Not Recorded
White Gypsy/Roma
African
British
Irish British
Asian Other
Chinese
British Somali
Somali
Algerian
Any other group
Hispanic
Italian
white british bangladeshi
Chinese vietnamese
Indian
bangladeshi
Arab
African and Carribean Mixed
Portuguese
Black Portuguese
Syrian
Eritreyan
Bangladeshi British
Caribbean British
Mixed Black and White
SriLankan
Mixed British
Kurdish British
Turkish British
Albanian British
Russian British
Congolese British
Ethiopian British
Russia
Russian
White: Any other background
Brazilian
Mixed Asian
Somali British
Religion
Please choose a value
Christianity
No religion affiliation or belief
Jewish
Hindu
Buddhist
Muslim
Catholic
Prefer not to say
agnostic
Not recorded
Sexual Orientation
Please choose a value
Bixsexual
Gay Man
Gay Woman/Lesbian
Heterosexual/Straight
Other
Prefer Not To Say
Disability
Please choose a value
Yes
No
Prefer Not To Say
If Yes
Sensory Impairment (such as being blind/having a visual impairment or being deaf/having a hearing impairment)
Physical Impairment (such as using a wheelchair to get around and/or difficulty using your arms)
Learning Disability (such as Downs Syndrom or Dyslexia) or Cognitive Impairment such as Autism or Head-Injury)
Mental Health Condition (such as Depression or Schizophrenia)
Long-standing illness or health condition (such as Cancer, HIV, Diabetes, Chronic Heart Disease, or Epilepsy)
Other
Medical Condition
Contact Information
Address 1
Address 2
Town
Post Code
Telephone
Mobile
Email
Education/Work Information
Are you currently in Education, Employment or Training?
Please choose a value
Yes
No
Name of current school, college or employer
Style of study or work
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Full Time
Part Time
Institution/Work start date
School year or job title
Emergency Contact
Title
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Mr
Mrs
Ms
Miss
Dr
Full Name
Relationship
Address
Postcode
Telephone
Mobile
Other Information
Do you attend any other youth club in Tower Hamlets?
Please choose a value
Yes
No
Not Sure
Do you have any medical conditions that may require support?
Please choose a value
Yes
No
Do you have any caring responsibilities at home?
Please choose a value
Yes
No
Not Sure
Reason for joining youth club (hold CTRL to select more than 1 option)
Socialise With Friends
Meet New People
Nowhere to Go, Want to Do Something
Want Careers & Employment Advice
Learn Something New/Gain New Skills
To Play Sport and Games
To Go Somewhere Safe/Feel Safe
To Do Outdoor Activities and Go on Trips
To Get Help, Support and Advice
Been Asked to Attend Youth Club
Medical Information
Allergies, Asthma & the Immune System
Blood Disorders
Bones, Muscles & joints
Brain & Nervous System
Cancer & Tumours
Digestive System
Genetic, Chromosomal & Metabolic Conditions
Growth, Hormones & Diabetes
Heart & Cardiovascular System
Kidneys & Urinary System
Learning Disorders
Lungs & Respiratory System
Mouth & Teeth Problems
Overweight and Obesity
Sexual Health & Reproductive System
Sight, Speech & Hearing
Skin, Hair & Nails
Which Centre are you joining?
Please choose a value
A-Team Arts
Christian Street
Collingwood
Columbia
Haileybury
Involvement Team
Limehouse
St Andrews Wharf
Tramshed
Wapping
Youth Voice and Influence
Privacy Notice Approval
Do you give permission to London Borough of Tower Hamlets Youth Service to collect and store information about you and the services you access for monitoring purposes?
Please choose a value
Yes
No
Not Sure
Do you understand that the data collected may be shared with other local authorities and partner organisations to support you?
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Yes
No
Not Sure
Do you understand that any data collected will be held in accordance with the General Data Protection Regulation? To find out more, please visit www.towerhamlets.gov.uk/content_pages/legal_notices/legal_notices.aspx
Please choose a value
Yes
No
Not Sure
I agree that I have spoken to my youth engagement worker/officer about the programme available to me and been given a youth centre induction
Please choose a value
Yes
No
Not Sure
Do you confirm that you have been shown the Privacy notice or made aware of where you can access the privacy notice?
Please choose a value
Yes
No
Not Sure
Approval for new members aged 11-12 years of age
Young Person Full Name
Parent/Guardian Full Name
Assessment Information
Health & Development
Parents & Carers
Family & Environmental
Risk & Protective Factors
Consent
I give consent for my child's image & audio to be used by Tower Hamlets Council & its partners for social media, monitoring & publicity purposes
Please choose a value
Yes
No
Submit