Attendee sign-up

At Coin Street and the Colombo Centre we want to ensure sessions are safe, supported and accessible. Our activities are subsidised or free and priority is given to people who live in North Lambeth and North Southwark. If you are filling in this form for someone else (e.g. your child), please enter their details at the top of the form. If you (or your child) want to attend a session at the Colombo Centre, you may need a Colombo membership card. To receive a Colombo membership card, you will need to complete the health form and have it signed off by a staff member before being able to attend a Colombo Centre session. Please allow time for this process on your first visit.

Activity where attendee is being registered * Please select the activity where the attendee is being registered

Please tick if you are registering as a volunteer Being a volunteer means you support the running of youth and community programme activities at Coin Street

Title This is only required if the attendee uses a title

If 'Other' title, please state

First name * Please ensure you enter the name of the person being registered (if this is not you). If you are a parent or carer registering your child, please enter your contact details under 'Contact 1' in the section below.

Last name *

Nickname

Date of Birth * e.g. 26/05/2001

Contact relationship type You are stating that you are the adult responsible for this young person and give your consent to be registered on Upshot (which includes permission to attend sessions).

Contact first name

Contact last name

Gender *

Faith

Ethnic group *

If 'Other ethnic group', please describe

Address line 1 *

Town/City *

Postcode *

Borough *

If 'Other' borough, please state

Contact Number 1 * If the person being registered is under 18 and the parent/carer is happy for the Coin Street team to contact them, please put their number here, otherwise, please enter in the parent/carer contact number

Contact email address * If the person being registered is under 18 and the parent/carer is happy for the Coin Street team to contact them, please put their email address here, otherwise, please enter in the parent/carer contact email

Please share the name of the school or learning provision attended. * If the attendee is under 18 and not in education, please enter: not in education

Does the attendee have any allergies? *

Please specify (allergies)

Does the attendee have a disability? *

Please specify (disability)

Does the attendee have additional needs? *

Please specify (additional needs)

Please detail any additional medical conditions, phobias, sensitivities and further information not mentioned above: * Please state ‘none’ if not applicable. This can also refer to neurodiversity and individual differences diagnosed as Autism Spectrum Condition, ADHD, Dyslexia, Dyspraxia, Dyscalculia, Tourette Syndrome, mental health conditions, acquired brain injury and chronic neurological conditions.

If the attendee has been referred by another organisation/agency/family support, please provide details:

Please state other agencies involved (GP/social services/home support/befriending services/transport etc.)

Additional information for children being registered, please select any options that apply *

Emergency Contact 1 - Full name, relationship to attendee, phone number, email address * We like to know who to contact if we need to reach someone in an emergency ,so please provide all the details requested

Emergency Contact 2 - Full name, relationship to attendee, phone number, email address

We would like to contact the attendee (and the parent/guardian/carer if applicable) with updates and changes to programme activities and events using the contact details provided. Do you give us permission? * If we cancel a session, it would be useful to let you know beforehand, so you don’t find out when you arrive.

How did you find out about this activity? *

If 'Other' please specify

Keep in touch by subscribing to our e-newsletters We’d love to keep in touch and updated with news, events, activities and special offers - you can unsubscribe any time

If the attendee is under 18, please confirm if you give permission for the child/young person named above to return home alone, or if you or another named responsible adult will collect them *

I give permission for the use of photos or other media featuring me.

I give permission to receive emails from Coin Street Youth and Community Programmes via Upshot

To access the Colombo Centre, you may need a membership card. This can only be issued once the health form below has been completed and signed-off by a designated member of staff. All information is used in the strictest of confidence and shared only to ensure that we make informed decisions about safety and accessibility for people who attend.

Has your doctor ever stated that you have a heart condition and that you should only do physical activity recommended by a doctor? If yes, please give details.

Have you ever had chest pain when not doing physical activity or do you feel pain in your chest when you do physical activity? If yes, please give details.

Do you lose your balance due to dizziness or do you ever lose consciousness? If yes, please give details.

Do you have a bone or joint problem that could be made worse by a change in your physical activity? If yes, please give details.

Do you currently take drugs or medication on a regular basis that have been prescribed by your doctor? If yes, please give details. Some examples include medication for: epilepsy, asthma, blood pressure, a heart condition and diabetes

Do you know of any other reason why you should not do any physical activity? If yes, please give details. Please include anything that may be useful to consider including: past injuries, surgeries, pregnancy, smoking

Name of staff member confirming sign-off, and referral for card issue For staff use only

Date of referral for card issue Fo staff use only

Date of card issue For staff use only

I understand that the information recorded on this form may be stored as hardcopy and electronically by Coin Street Community Builders. I agree that this information can be used by Coin Street Community Builders, their partners, funders and for the purposes of monitoring activities that I, or the person for whom I am completing this form, may attend. Find our privacy notice here: https://coinstreet.org/privacy-policy/

I accept the organisation's Terms & Conditions and Privacy Policy *

Finally, please confirm you are a real person. *

Sign up with Coin Street Youth and Community Programmes

Health and Wellbeing Questions

Confirmation

Terms & Conditions and Privacy Policy