Wellbeing – St Pancras Community Association

Name *

First

Last

This form must be completed by the parent or guardian on behalf of someone aged under 18, or by someone aged 18 or more who is registering in their own name.

If completing on behalf of someone else, what is your relationship to that person? eg father, mother

Name of the adult completing this form, if this is being done on behalf of child or young person

Email *

Sign up to our newsletter?

Gender *

Phone number *

Please provide your number, a mobile is best. We’ll use this if we need to get in touch with you to discuss your registration.

Address *

Post code *

All our activities are in Camden, so it’s helpful to know which part of London you’re from. We won’t share your information with anyone else.

Date of birth (in format dd/mm/yyyy) *

This is the date of birth of the person who is registering.

Please select all activities you are interested in:

Select all that apply.

Disability

Do you have any long-standing illness, disability or infirmity? If yes, please specify

Ethnicity

Please specify your ethnicity, or type ‘Prefer not to say’

Medical details

Please indicate any medical conditions we should know about.

Emergency contact information *

Please provide a name and contact number of someone we can contact in case of an emergency

Are you happy to have your photograph taken whilst taking part in activities with St Pancras Community Association and to have your photograph displayed on our website which is available for the public to see?

I give permission (please select all that apply) to be contacted via:

Email – this includes our newsletter where we send updates about the programme
Telephone
Text message
Post

I give permission for my registration form information to be accessed by SPCA staff and instructors: *

Yes

GDPR (General Data Protection Regulation) replaces the Data Protection Act from May 2018.

Where did you hear about the Wellbeing programme?

Programme

Register for a membership