Family Membership Form
 
 
X



Start Well Family Centres (Sure Start Children's Centres) want to ensure that all services and activities provided make a difference to children, families and communities. We do this by recording and looking at why and how people use the different Start Well services and activities. Your information will be kept safe and secure and treated with care and respect. As a data processor, we have a duty to make sure that your information is accurate and is shared in line with the principles of GDPR (General Data Protection Regulations) and the Data Protection Act 2018. For more information around how we use your data, please read our privacy notice:

https://www.wigan.gov.uk/Council/DataProtection-FOI-Stats/Privacy-notices/Data-Primary-Privacy-Notice.aspx
Consent
I/We consent to you sharing relevant information within Start Well and the following agencies delivering Start Well Services and Activities.





I understand that:

  • My Information will not be shared with anyone outside of these agencies without my explicit consent.
  • My data will not be kept longer than is necessary for the purpose of my registration and my details will be destroyed after three years if I have chosen not to access any of the services.
  • I agree to you contacting me to update my details in order to keep your records accurate.
Main Contact Signature: Second Contact Signature:
Date:
Date:
https://www.wigan.gov.uk/council/the-deal/index.aspx
 
Position: * Gender:*
Title: * Date of birth:*
First Name:* Ethnicity:
Last Name:* Nationality:
First Language:
Location*
Telephone Number: Mobile:
Email:
 
Line 1:*
Line 2:
Line 3:
Postcode:*
 
Name of GP
Line 1:
Line 2:
Line 3:
Postcode:
 
Health Visitor
Line 1:
Line 2:
Line 3:
Postcode:
 
Are all family members registered with a dentist? Employment status:
Are you a lone parent? Expecting a child?
Due Date:
Do you have a special need or disability? Are you in training or studying?