Registration Form
PARTICIPANT DETAILS
Name
Address
Postcode
Mobile No
Date of Birth
ACTIVITY (Please Circle):
Taster Session:
Yoga / Clubbercise / Buggy Fitness /
Rebounding / Basketball Fitness Circuit
8 Week Programme: Yoga / Clubbercise / Buggy Fitness/
Rebounding / Basketball Fitness Circuit /
Buggy Walk
Have you used the gym or participated in ANY fitness
classes in the last four weeks
(Please Circle) : Yes / No
CONTACT AND MEDICAL INFORMATION
Emergency Contact Name
Emergency Contact Number
Email
London Borough of Havering
Sports Development is committed
to sports equity and access for all
in its sporting activities. In order for
us to monitor who takes up these
opportunities, we need to ask for
some details about you/your child.
What is your or your child’s
ethnicity? (Please Circle)
White: W1 British
W2 Irish
W3 White Other
……………………………………….
Dual: D1 White and Black Caribbean
D2 White and Black African
D3 White and Asian
D4 Other mixed
……………………………………….
Asian or British Asian:
A1 Indian
A2 Pakistani
A3 Bangladeshi
A4 Other Asian
………………………………………..
Black or Black British:
B1 Caribbean
B2 African
B3 Other Black
…………………………… …………..
Any medical condition of participant we should be aware?
e.g. asthma, diabetes
Chinese or other ethnic group:
C1 Chinese
C2 Any other
……………………….…………………
MY CHILD (ages 15 and under):
Do you consider yourself / child to
be disabled? If so what is the nature
of their impairment?
WILL BE COLLECTED/CAN LEAVE ON THEIR OWN
at the end of the session (please delete as appropriate)
Photographs may be taken during the courses for
promotional purposes. If you do not want your child to
feature in such photos please tick the box
Culture and Leisure Services may wish to send you
promotional material regarding forthcoming activities and
events. If you do not wish to receive such information then
please tick the box
Signature of Participant or Parent/Carer/Guardian if
aged 15 and under
Please
specify…………………………………
The information in this document
will remain confidential and
contact numbers will not be
supplied to any other party.
Please return to:
Elvan Dixon
Youth Sport Officer
The Stableblock, Langtons
Billet Lane,
Hornchurch RM11 1XJ
[email protected]
Agreement
HAVERING US GIRLS PROGRAMME
The programme is to target ‘inactive’ female Havering residences (people who have not used
the gym or participated in a fitness class in the last four weeks, aged +11 years). Funding by
FREESPORT has given us the opportunity to provide this programme of sessions for FREE for the
set period.
Due to this rare opportunity, we ask you only commit to this programme if you are ‘inactive’,
female, +11 years, Havering resident, and are able to attend at least 6 of the 8 sessions of your
selected class.
Non-attendence to any session could resolve in removal from the Us Girls Project. Therefore,
please inform the instructor or Elvan Dixon if you are unable to attend a session or continue on
the programme.
Limited Spaces/Selection
Following the Us Girls Festival on Saturday 20th February 2016 you will be informed if you have
been successful in gaining a space on to the Us Girls Programme and for which class.
Programme Dates
The Programme will be starting the week of Monday 22nd February 2016 for 8 weeks ending the
week of Monday 11th April 2016, except Yoga which will finish on Monday 18th April 2016 due to
a class closure on Bank Holiday Monday 28th March 2016.
Loyalty Card
If you are allocated a space on the programme you will be given an Us Girls Loyalty Card where
you can work towards receiving Us Girls Gifts (to be taken to every session you attend).
If you agree to these terms please sign:
Participant Name
Date
Name of Parent/Carer/Guardian if participant aged 15 and under:
Signature of Participant or Parent/Carer/Guardian if aged 15 and under
Please return to Elvan Dixon, Youth Sport Officer
The Stableblock, Langtons, Billet Lane, Hornchurch RM11 1XJ
[email protected]
Phone: 01708 431233 Text: 07971 453719
www.havering.gov.uk/usgirls