Lewisham Family Hubs Registration

Family Information

Family Address:

Postcode

Telephone number (including area code):

Mobile phone number (including country code):

Your email address:

Parent / Carer

First Name

Surname

Relationship to child

Date of Birth

Gender / Pronoun

Disability

Religion

Language

What is your Ethnicity?

Please choose and optionAsian & WhiteAsian OtherBangladeshiBlack AfricanBlack African & WhiteBlack BritishBlack CaribbeanBlack Caribbean & WhiteBlack OtherChineseGypsy/RomaIndianMixed Race OtherOther Ethnic GroupPakistaniTraveller of Irish HeritageWhite BritishWhite IrishWhite OtherPrefer not to say

Are you pregnant?

NoIf yes, due date

Parent/Carer

First Name

Surname

Relationship to child

Date of Birth

Gender / Pronoun

Disability

Religion

Language

What is your ethnicity?

Please choose and optionAsian & WhiteAsian OtherBangladeshiBlack AfricanBlack African & WhiteBlack BritishBlack CaribbeanBlack Caribbean & WhiteBlack OtherChineseGypsy/RomaIndianMixed Race OtherOther Ethnic GroupPakistaniTraveller of Irish HeritageWhite BritishWhite IrishWhite OtherPrefer not to say

Are you pregnant?

NoIf yes, due date

Child 1

First Name

Surname

Gender/Pronoun

Date of Birth

Disability

What is your ethnicity?

Please choose and optionAsian & WhiteAsian OtherBangladeshiBlack AfricanBlack African & WhiteBlack BritishBlack CaribbeanBlack Caribbean & WhiteBlack OtherChineseGypsy/RomaIndianMixed Race OtherOther Ethnic GroupPakistaniTraveller of Irish HeritageWhite BritishWhite IrishWhite OtherPrefer not to say

Child 2

First Name

Surname

Gender/Pronoun

Date of Birth

Disability

What is your ethnicity?

Please choose and optionAsian & WhiteAsian OtherBangladeshiBlack AfricanBlack African & WhiteBlack BritishBlack CaribbeanBlack Caribbean & WhiteBlack OtherChineseGypsy/RomaIndianMixed Race OtherOther Ethnic GroupPakistaniTraveller of Irish HeritageWhite BritishWhite IrishWhite OtherPrefer not to say

Child 3

First Name

Surname

Gender/Pronoun

Date of Birth

Disability

What is your ethnicity?

Please choose and optionAsian & WhiteAsian OtherBangladeshiBlack AfricanBlack African & WhiteBlack BritishBlack CaribbeanBlack Caribbean & WhiteBlack OtherChineseGypsy/RomaIndianMixed Race OtherOther Ethnic GroupPakistaniTraveller of Irish HeritageWhite BritishWhite IrishWhite OtherPrefer not to say

Child 4

First Name

Surname

Gender/Pronoun

Date of Birth

Disability

What is your ethnicity?

Please choose and optionAsian & WhiteAsian OtherBangladeshiBlack AfricanBlack African & WhiteBlack BritishBlack CaribbeanBlack Caribbean & WhiteBlack OtherChineseGypsy/RomaIndianMixed Race OtherOther Ethnic GroupPakistaniTraveller of Irish HeritageWhite BritishWhite IrishWhite OtherPrefer not to say

Fair processing and consent

Here at Lewisham Family Hubs, we take your privacy very seriously. With your consent we will process, retain and store your personal data on behalf of the London Borough of Lewisham in line with the General Data Protection Regulation (GDPR) (EU) 2016/679.

Your data is stored on a secure database controlled by the London Borough of Lewisham for the purposes of monitoring, evaluation and for the provision of Lewisham Children and Young People’s Partnership services, without consent no service can be provided.

Your personal data and contact details will not be shared with any other third party or organisation but may be shared with other Family Hubs, and other partnership organisations.

You have the following rights regarding your personal data:

• The right to withdraw consent at any time
• The right to request your personal data is deleted
• The right to access to your personal data

For more information regarding the use of your personal data please see the London Borough of Lewisham’s Privacy Notice at https://lewisham.gov.uk/about-this-site/privacy/main-privacy-statement or make a request to Stephen Williams, Data Protection Officer, at DPO@lewisham.gov.uk.

I understand that by providing my consent I am confirming I understand how and why my personal data is used and give permission for Family Hubs to store and update my personal details.

Yes

I am a parent/legal guardian of a child/children under the age 16 and give consent for Lewisham Family Hubs to store and use my child/children’s personal data for the purposes of the service.

Yes

I give permission to Family Hubs and any relevant partner organisation to contact me regarding services available and my access to them by:

Yes

Telephone

YesNo

Email

YesNo

Post

YesNo

Date: