Young Tower Hamlets
Identity
Forename
Surname
Date Of Birth
Day
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2nd
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22nd
23rd
24th
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26th
27th
28th
29th
30th
31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Gender
Please choose a value
Male
Female
Not Recorded
Demographic
Ethnicity
Please Select
African
African and Carribean Mixed
Any other Asian background
Any other Black / African / Caribbean background
Any other Ethnic group
Any other Mixed / Multiple Ethnic background
Any other group
Arab
Asian Bangladeshi
Bangladeshi
Black African
Black Caribbean
Caribbean
Chinese
Gypsy or Irish Traveller
Indian
Not Recorded
Other
Pakistani
Prefer Not To Say
Somali
Vietnamese
White English / Welsh / Scottish / Northern Irish / British
White Irish
White and Asian
White and Black African
White and Black Caribbean
White: Any other background
Religion
Please Select
Hindu
Jewish
Muslim
Buddhist
Christianity
No religion affiliation or belief
Catholic
Prefer not to say
agnostic
Not recorded
Sexual Orientation
Please Select
Bixsexual
Gay Man
Gay Woman/Lesbian
Heterosexual/Straight
Other
Prefer Not To Say
Disability
Please Select
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
County
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
Please choose a value
Full Time
Part Time
Institution/Work start date
Day
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
25th
26th
27th
28th
29th
30th
31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
School year or job title
Emergency Contact
Title
Please Select
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 Select
Yes
No
Not Sure
Do you have any medical conditions that may require support?
Please Select
Yes
No
Do you have any caring responsibilities at home?
Please Select
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 Select
A-Team Arts
Christian Street
Collingwood
Columbia
Haileybury
Involvement Team
Limehouse
St Andrews Wharf
Tramshed
Wapping
Youth Voice and Influence
Bigland Green Youth Centre
Old Castle Street Youth Centre
Bromley-By-Bow Youth Centre
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?
Please choose a value
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
Please confirm the following details are correct
×
Identity
Forename
Surname
Date Of Birth
Gender
Please choose a value
Demographic
Ethnicity
Please Select
Contact Information
Address 1
Town
County
Post Code
Mobile
Email
Education/Work Information
Are you currently in Education, Employment or Training?
Please choose a value
Name of current school, college or employer
Emergency Contact
Title
Please Select
Full Name
Relationship
Address
Postcode
Mobile
Other Information
Do you have any medical conditions that may require support?
Please Select
Do you have any caring responsibilities at home?
Please Select
Reason for joining youth club (hold CTRL to select more than 1 option)
Which Centre are you joining?
Please Select
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
Do you understand that the data collected may be shared with other local authorities and partner organisations to support you?
Please choose a value
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
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
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
Approval for new members aged 11-12 years of age
Young Person Full Name
Parent/Guardian Full Name
Consent
I give consent for my child's image & audio to be used
Please choose a value