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Summer 26 booking form

Please complete as thoroughly as possible, if you would prefer to complete this over the telephone, please call 01255475001.

Once submitted we will contact you ASAP, if you are waiting on a confirmation of a placement on a course then please do check your spam and junk folders.

1.Your full name
2.Your Date of Birth
3.Contact Details(Required.)
4.NEXT OF KIN NAME(Required.)
5.NEXT OF KIN - contact number(Required.)
6.Relationship to Child
7.Children/Young persons details (Child 1):(Required.)
8.Children/Young persons details (Child 2):
9.Children/Young persons details (Child 3):
10.Children/Young persons details (Child 4):
11.If you have more than 4 children, please answer 'Yes' below and we will contact you for their details.
12.Please give details of any services working with the family below.
13.Reason for referral, Please give us as much information as possible around how we can support you and if you have seen a course advertised that you would like to attend please include this.
14.I am interested in the following courses / workshops
15.Where did you hear about EXTRA? If via your child's school please tell us which school.
16.I consent to my personal details being kept on a secure database to be contacted by EXTRA, all data is kept confidential in compliance with GDPR.(Required.)
17.Your child/children’s information:

If you consent to us keeping personal information on your child/children (under the age of 16) on our secure database, please tick to confirm:(Required.)
18.REGISTER

Name

If you attend a course, workshop or parent peer support group the facilitators of the event will keep a register with you name for our record of attendance and fire safety.

If you consent to us passing on your name for that purpose please tick to confirm:
19.Telephone number

On our registers we like to have your phone number in case the facilitators need to contact you to cancel a session, for instance.

If you consent to us passing on your telephone number for that purpose please tick to confirm:(Required.)
20.MONITORING

Within courses, workshops and support groups we will ask you to complete questionnaires so that we can evaluate the impact of our support and report this to our funders. Your responses will be entered onto our database but the information given to our funders is kept anonymous.

If you consent to us keeping the responses to your questionnaires on our secure database, please tick to confirm:(Required.)
21.I would like to receive updates and leaflets via email for what courses and workshops are running the following term
22.I confirm that I agree to Extra – Support for Families storing my personal information (and that of my child/children) as indicated in the sections ticked(Required.)
23.I confirm that I agree to Extra – Support for Families storing my personal information (and that of my child/children) as indicated in the sections ticked

Please print your name & date below to E-Sign this privacy statement.
24.WITHDRAWING CONSENT

You have the right to withdraw consent to EXTRA storing your information, or any part of it, at any time. If you wish to do so, please contact EXTRA:

Post: Extra – Support for Families, Jaywick Community Resource Centre, Brooklands Gardens, Jaywick CO15 2JP

Email: admin@extrasupportforfamilies.co.uk

Phone: 01255 475001