Activities Registration Form
All information given will be treated as strictly confidential
Office use only Participant ID ______________________
To register for our FREE Right Here activities for 18-25 year olds living in Brighton & Hove,
please complete this form and return it to us, either by emailing it to:
rh.activities@sussexcentralymca.org.uk, or posting it to:
Right Here Activities, Reed House, 47 Church Road, Hove, BN3 2BE
Name
Date of Birth
Address
Telephone
Age
Email address
Which Right Here activities are you interested in?
Do you have any physical or mental health conditions which may affect you during the Right Here activities?
□ Yes □ No
If yes, please provide details. Please continue on a separate sheet if necessary.
Please give names and contact details of any other professionals who may be providing you with some support,
e.g. substance misuse, mental health services, youth offending services, etc.
Are you currently suffering, or have suffered, from any of the illnesses listed below?
□ Heart trouble
□ Joint problems
□ Severe stress reaction
□ Hernia or rupture
□ Depression/anxiety
□ Other mental health issues
□ Lung disease
□ Diabetes
□ Serious accident
□ Kidney/bladder disorder
□ Hearing/sight problems
□ Stomach/bowel trouble
□ Allergies
□ High blood pressure
□ Back/neck problems
□ Skin problems
If you have ticked any of the above, please provide details…
□ Jaundice/hepatitis
□ Headaches/migraines
□ Asthma
□ Fits / blackouts / epilepsy
□ Surgical operations
□ Other
(Optional questions) If you have experienced mental health issues:
Have you had a mental health diagnosis?
□ Yes □ No
Details ………….…………………………………….
……………………………………………………………………………………………………………………………………...
Have you used any mental health services?
□ Yes □ No
Details ………….…………………………………….
……………………………………………………………………………………………………………………………………...
□
There may be occasions when it is helpful to discuss what support you might need to access Right Here
activities. We would do this with you and any other professionals providing you with support. Please tick
this box if you would prefer us not to speak to other professionals without your prior consent
Are you currently taking any medication?
□ Yes
□ No
□ Prefer not to say
If yes, please provide details…
In case of medical emergency, please provide
details of your GP
Name
Telephone
Address
Next of kin / emergency contact
Name
Telephone
Address
How did you find out about the activities being offered by Right Here?
Please indicate how you would prefer to be contacted about Right Here activities
□ Email
□ Telephone
□ Text
□ Post
Declaration
Your personal information might be shared with the activity instructor or other professionals involved in your
support. If you would not like this to happen, or would like to discuss this further, please inform Laurence Davies,
the Activities Co-ordinator.
The information I have given on this form is accurate to the best of my knowledge. I agree to inform Right Here if
any of the information on this form changes in the future. I understand that taking part in Right Here activities is at
my own risk and that Right Here Brighton & Hove, YMCA DownsLink Group, Brighton and Hove City Council, Mind,
Brighton Housing Trust and Care Coops do not accept any risk, liability, damage or other consequence caused to
any person or property during my participation.
I agree not to attend Right Here activities under the influence of alcohol or illegal substances.
Signature
Date
Right Here will occasionally take photographs of activities to use in promotional materials. If you
do not want your photograph to be used, please tick here:
Right Here will add your email address to our mailing list if you have given us one. If you do not
want to go on our mailing list, please tick here:
□
□
Equalities Monitoring Form
The reason why we ask you these questions is so we can:
 Make our services open to everyone in the city,
 Treat everyone fairly and appropriately when they use our services,
 In consultations, make sure that we have views from all across the city.
The Equality Act 2010 makes these aims part of our legal duties. Your answers help us
check that we have met the law and help improve our services.
Your answers are completely anonymous and confidential. We will only use them to make
services better. Information from forms is combined so you cannot be identified.
A short guide to these questions is available. Please ask if you would like it. You can also
ask for a large print version (Email rh.activities@ymcadlg.org or call 01273 222562 for
assistance).
……… years
 Prefer not to say
What age are you?
What gender are you?
 Male
 Female
 Other – please state … …………
 Prefer not to say
Do you identify as the gender you were
assigned at birth?
For people who are transgender, the gender they
were assigned at birth is not the same as their own
sense of their gender.
 Yes
 No
 Prefer not to say
How would you describe your ethnic origin?
White
 English / Welsh / Scottish /
Northern Irish / British
 Irish
 Gypsy or Irish Traveller
 Any other White back-ground
(please give details)
……………………………
Asian or Asian British
 Bangladeshi
 Indian
 Pakistani
 Chinese
 Any other Asian background
(please give details)
……………………………
Black or Black British
 African
 Caribbean
 Any other Black background
(please give details)
………………………………
Other Ethnic Group
 Arab
 Any other ethnic group
(please give details)
……………………………...
 Prefer not to say
Mixed
 Asian & White
 Black African & White
 Black Caribbean &White
 Any other mixed
background (please give
details)
……………………………
Which of the following best describes your sexual orientation?






Heterosexual/ Straight
Lesbian/ Gay woman
Gay man
Bisexual
Other (please state) …………………………………………………………..
Prefer not to say
What is your religion or belief?
 I have no particular religion
 Buddhist
 Christian
 Hindu
 Jain
 Jewish
 Muslim
 Pagan
 Sikh
 Agnostic
 Atheist
 Other (please state)
…………………………….
Are your day-to-day activities limited
because of a health problem or disability
which has lasted, or is expected to last,
at least 12 months?
 Other philosophical belief
(please state)
………………………..............
 Prefer not to say
 Yes a little
 Yes a lot
 No (do not answer the next question)
 Prefer not to say (do not answer the next
question)
If you answered ‘yes’, please state the type of impairment. If you have more than one please
tick all that apply. If none apply, please mark ‘other’ and write an answer in.
(Examples are given in the guidance)




Physical Impairment
 Long-standing Illness
Sensory Impairment
 Mental Health Condition
Learning Disability/Difficulty
 Developmental Condition
Other (please state) ………………………………………………………………………
Are you a carer?
A carer provides unpaid support to family or friends
who are ill, frail, disabled or have mental health or
substance misuse problems.
If yes, do you care for a…….?
 Yes
 No
 Prefer not to say
 Parent
 Child with special needs
 Other family member
 Partner / spouse
 Friend
 Other (please give details)
…………………………………………
Armed Forces Service:
Are you currently serving in the UK Armed Forces (this includes
reservists or part-time service, eg: Territorial Army)?
 Have you ever served in the UK Armed Forces?
 Are you a member of a current or former serviceman or
woman’s immediate family/household?

 Yes
 No
 Yes
 Yes
 No
 No
Please return this form to the person who gave it to you.
The data controller for this form is Brighton & Hove City Council
Thank you for completing this form – it will help us improve our services for
everyone.