Group registration

Please select the group/activity you would like to attend?*

Date of the group/activity you would like to attend*

First name*

Surname*

Borough of residence*

Address*

Postcode*

Phone no.*

Email*

Date of Birth*

Gender*

Ethnicity

Do you have a disability or health condition?

Primary language spoken*

Do you need an interpreter? If yes, please state which language

Do you have any access needs? If yes, please specify.

Are you expecting a baby?*

Is this a multiple birth?*

Are you a first-time parent?*

Please tell us who signposted you to this group (e.g. Midwifery, GP) otherwise please select self referral.

Please use the section below to tell us about another adult you would like to bring to the group and any children in your family (including unborn).

Please use the “add another individual” button to add each individual.

Name*

Surname*

Date of Birth (if the child is unborn, please leave this field empty and enter the EDD (Expected Date of Delivery) below)

Please provide your unborn child’s EDD (Expected Date of Delivery)

Relationship to you*

Add another individual

Please share any other information that you think would be useful to know before attending the group/activity, including any risks or concerns you may have:

By submitting this form, you are confirming that:

- the information provided is correct to the best of your knowledge

- the referral has been discussed with the family, who have agreed to a referral being made to Home-Start

Westminster.

- you as the referrer and the family, agree for your details to be stored in our database in accordance with data

protection legislation (see our Privacy Notice).

You understand that we can only accept referrals which have been discussed with and agreed by the family. The

information provided in this referral will be held in confidence but may be shown to the family if requested. Where a family has agreed to our support, we will ask them to sign our privacy notice.

You can find our Privacy Notice here for reference.