This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Making Changes by Making Changes Blackpool Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "Privacy Statement You can withdraw your consent at any time by emailing making.changes@blackpool.gov.uk. For further information on how your data is processed as part of the programme, please see our privacy statement below. Active Blackpool are the data controllers for the personal information you have provided in this form. The Council’s data protection officer can be contacted at Dataprotectionofficer@blackpool.gov.uk or by writing to Data Protection Officer, PO BOX 4, Blackpool, FY1 1NA. In relation to the privacy statement, further information is available on our website at www.blackpool.gov.uk/PrivacyNotices The child & family management service requires personal data to ensure we provide you the best possible service. The personal information on this form will be retained to demonstrate that consent was sought for the named person above and their family to take part in this programme. We will use the information provided to contact you in an emergency and ensure that staff delivering the sessions are aware of any medical or special support needs. The lawful basis for the Council to collect and use your personal information is because you have given us clear consent. We will collect the following information: your name, date of birth, medical information, contact details, medical history, height/weight/BMI and details of any medication. Your data will be stored securely and reported anonymously to Public Health. We do not transfer your information to a third country (that is a country outside of the EEA)." Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. Should the service provider be aware of any additional needs? Blind/partially blind Memory problem Hearing loss Housebound Does not speak English Poor mobility Learning and communication needs Physical disability Frail Other: This field is required. Please share some brief details regarding this referral Child Height (cm) Child Weight (kg) Child Centile Parent/Guardian Name Parent/Guardian Contact Info (if different from above) Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
