Universal Youth Work Young Person Registration Form

Welcome to Rotherham Early Help. In order to offer you a high quality service we would be pleased if you could supply us with the following details:

YOUR DETAILS

FIRST NAME AT BIRTH:		SURNAME:
PREFERED FIRST NAME NOW:
ADDRESS:		DATE OF BIRTH:	AGE:
		MY BIOLOGICAL GENDER IS?
		MY GENDER IDENTITY IS?
		MY PREFERED PRONOUN IS?
POSTCODE:	SCHOOL/COLLEGE/ PLACE OF WORK/OTHER
Your Mobile Number
Email Address
Home Tel Number

GDPR/DATA Protection - Information provided on this consent form will be used by Rotherham MBC to inform the safe delivery of activities and will be shared with health care professionals if and when required. Where there is an accident or incident we need to keep the consent form (electronic copy) together with a copy of the accident/incident form for 7 years or until the participant is 25 years old, whichever is longer; else the form will be

deleted within 14 days of the end of the visit.

ETHNICITY (Please tick whichever box would best describe yourself):
White	Asian or Asian British	Black or Black British	Mixed/Dual Background	Other (please state)
 British	 Bangladeshi	 African	 Mixed Other	 Chinese
 European	 Indian	 Caribbean	 Mixed – White & Asian	 Any Other Ethnic Group
 Irish	 Any Other Asian	 Any Other Black Background	 Mixed – White & Black African	 Yemeni
 Traveller of Irish Heritage	 Pakistani		 Mixed – White & Black African
 Gypsy/Roma			 Mixed White & Chinese
 Any Other White Background

Date:

Name of young person:

Signed by Young Person: