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0121 301 5990

Group Work

Young Parents Group Work Registration Form


If you would like to join our group we need to collect some information that will help us assist you further.   You will need to answer all questions otherwise you will not be able to submit the form.  If you are having trouble submitting the form just double check that you have answered all questions and I’m sure you’ll find you’ve missed one somewhere.  If problems persist please ring 0121 301 5990 or use the Contact Us page to let us know.

You will also need to complete the mood score self assessment quiz so once you have competed this form please don't forget to click on the link to the quiz.
All fields highlighted in red are mandatory.

YOUR DETAILS


















Yes, I wish to celebrate my birthday
No, I don't wish to celebrate my birthday




SHOULD ANYTHING HAPPEN TO YOU WHILST YOU'RE AT THE GROUP WE NEED THE FOLLOWING DETAILS








CONFIDENTIALITY


Yes, I accept this
No, I don't accept this


DATA PROTECTION - HOW WE WILL USE YOUR INFORMATION
In order for us to help you we need to gather, record and store your details in a confidential database. These details may contain your personal and sensitive or 'special' data. To comply with data protection legislation, we must tell you how we use and store this data and your rights concerning it. This information is contained in paragraph above.

The record of your case will be stored in a shared electronic case management system accessed by authorised staff and volunteers of Acacia Family Support to record your contact with the service. Paper copies of your data will also be stored securely and destroyed when either you turn 24, your child is 2 or you stop coming to group before then. We may use some of your information to produce demographic reports to funders. When doing this all identifying information is completely removed so that it is completely anonymised.


Yes, I accept

SMILE! ARE YOU READY FOR YOUR CLOSE UP?!
As this group is new and exciting, we would like to take some pictures of you and your child(ren) participating in the group. If this is ok with you, please read and sign below:

I give you all the permissions you need to copy, print, exhibit, transmit, and broadcast the contribution in all countries in the world by all means and, in all media, including the internet and social media channels. This consent includes, but is not limited to:

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and my child(ren) and/or record my and my child(ren)'s voice(s);

(b) Permission to use my and my child(ren)'s name(s); and

(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, on television, radio and electronic media, and in educational/awareness raising media.


Yes
No



SUBMIT >

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Need Help? If you need help or support or have any questions please call.
0121 301 5990
or click here to email us

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