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For Carers with a Birmingham postcode looking after a disabled, frail, or vulnerable family member or friend.

Full Name * Address * Postcode * Email Address * Telephone Number * I confirm I have registered with Birmingham Carers Hub
(It only takes minutes to register online here birminghamcarershub.org.uk YesNo Birmingham Carers Hub registration no. (if known) Do you have any health conditions that may impact your ability to tale part in gentle Yoga and movement? If you are unsure please always check with your doctor before starting any new exercise programme. YesNo If so please give brief details here: Are you filling out this form on behalf of someone else? YesNo

If so, please provide your name and email address below:

Full Name: Email Address Relationship to Carer All uses of personal data are controlled by the Data Protection Act (amended by the General Data Protection Regulations GDPR). Please see Birmingham City Council and Birmingham Carers Hub website for their privacy statements

Carer Consent Statement

I understand that I am giving my personal information to Barefoot Birmingham Yoga and Birmingham Carers Hub, on behalf of Birmingham City Council and other professional agencies you are working with; and you will keep it safe and only use it to assess my needs and help plan my care support. I understand that I can take away my consent at any time. I understand that without consent, this will make it difficult to assess my needs and arrange the support I need. I am aware that I can say if there is any particular organisation that I do not want to see my information, and you will not share it with my relatives or friends without my knowledge or agreement. I understand that there may be exceptional circumstances where the law says Birmingham Carers Hub must show/share this assessment with someone else. The information I give is true and accurate and I understand that action maybe taken against me, if I have given false information. Agree

How To Find Us

7 High Street
Harborne
Birmingham
B17 9NT
T: 0121 426 2633
E: hello@barefootharborne.co.uk

Barefoot Yoga Harborne Ltd. Company number 12553712

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