/ Referrer Details
Q1 / Name
Q2 / Your Role:
Parent/Carer / Other Relative / Medical Practitioner (i.e. Doctor, Nurse, Physiotherapist)
Q3 / Contact Telephone Number:
Q4 / Contact Email Address:
Who is the person you are referring
Q5 / Name
Q6 / Date Of Birth / Age: / Sex:
Ethnicity: / Male/Female
Q7 / Address and Postcode
Q8 / Telephone Numbers: / Home: Mobile:
Q9 / Email Address:
Q10 / Which District do you live in, please tick.
Ashfield / Gedling / Rushcliffe
Bassetlaw / Mansfield
Broxtowe / Newark& Sherwood
Nature of your disability or condition (Please tick all that apply)
Q11 / Physical Disability / Mental Health Condition / Hearing Impairment
Learning Disability / Visual impairment / Stroke
Q13 / Please provide more information on the disability or condition ticked:
Q14 / Please describe any other condition(s) that affect the person. i.e. Asthma, Epilepsy, Diabetes
Q15 / Please list any Specific support required or other concerns
Q16 / Please add any other relevant information that you feel we need to know.
Q17 / Please list any sports or activities this person has a particular interest in.
Q18 / Please provide contact details of a named emergency contact (including name, address and telephone number). This person will be contacted in the event of an emergency.
Name:
Address:
Telephone:

Data Protection Act 1998: Your personal information will be handled by Ashfield District Council, Everyone Active and Nottinghamshire County Council in accordance with the data protection act 1998. It will be used for the purpose of fulfilling the referral process, monitoring and evaluation and informing sport, health and fitness professionals. Where appropriate the information will be used by sport and leisure management. It will be kept on paper and computer for a maximum of 24 months.

I am happy for you to use my data in this way

I would like you to follow up this referral and I have given you all the information available to me to the best of my knowledge. I understand you may contact me for further information or clarification before acting on the referral.

I acknowledge the information given above is correct to the best of my knowledge at the time of completion. I undertake to inform you immediately if any of the above information changes. I undertake to use the fitness facilities only in accordance withthe instructions of the fitness staff. I acknowledge that any use of the facilities and equipment and participation in physical activity is entirely at my own risk -Please add your name and date below.

Name:______,
Date:______

We aim to contact you regarding your referral with-in 5-10 working days.

Please return completed forms to Pete Edwards, Sports Development Officer Disability Sport, Sport Nottinghamshire, Lee Westwood Sports Centre, Nottingham Trent University, Clifton Lane, Nottingham, NG11 8NS or email