Weigh Forward Sign-up - Active Lifestyles Sefton

Sign-up Form

During the next 6 weeks you will be shown various evidence-based strategies and facts in respect of weight management to help you to achieve weight loss and to improve your wellbeing. Each week will consist of an hour session including any questions & answers you may have.

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How did you hear about us?*
Online Courses
Face to Face Courses
Personal Details
Name*
First Last
Date of Birth*
Participants must be 18 and over.
Address*
Street Address Address Line 2 City ZIP / Postal Code
Phone*
Email*
Starting measurements*
Height Weight Waist
About You
These questions are optional and are asked in accordance with the Privacy Notice.
1. How old are you?
2. Are you
3. Do you consider yourself to have the protected characteristic of gender reassignment?
Regarding the above statement. Section 7 (1) of the Equality Act states that: ‘A person has the protected characteristic of gender reassignment if the person is proposing to undergo, is undergoing or has undergone a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex. (Please note that ‘process’ does not mean only a medical process)
3a. If you answered ‘yes’ to the above, do you currently identify with your birth sex?
3b. If you do not live as the sex you were given at birth, are you:
4. How would you describe your sexual orientation?*
5. Disability*
If you have ticked any of the boxes above, or you have cancer, diabetes or HIV this would be classed as ‘disability’ under the legislation.
6. Do you consider yourself to be ‘disabled’?
7. Religion Belief*
8. Race/ Ethnicity*
Socio Economic Status*
Living Well Sefton – Organisations/ Services
Active Lifestyles is part of the Living Well Sefton programme, which allows me to access other organisations/services. By giving permission to access the benefits of what the wider service can offer I am allowing my data to be input onto the integrated database. By having your data on our shared system does not mean you will be contacted by other services; only those services you give permission to be referred to can share your data. I consent to my information being passed on to the following additional services if required
- Select All
- May Logan
- Brighter Living Partnership
- Feelgood Factory
- Smoke Free Sefton
- Citizens Advice Sefton
- Sefton Carers Centre
Consent*
I agree.
I would like to voluntarily engage in the Active Lifestyles Group Weight Management Programme and workshops aimed at improving my physical health and well-being. I understand that the purpose of the programme is to help improve my nutritional and weight management needs and assisting me in making long-term lifestyle improvements.

Please note: If you have any specific dietary / nutritional requirements that have been recommended for you by a Health Professional directly involved in your care, you must ensure that you continue to follow the advice you have been given and ask for clarification if you have any questions or queries.

I agree to undergo health screening tests including height, weight and waist circumference in order to check my progress. As part of the appointment, I understand I will also be asked sensitive questions around equality information, however I appreciate I am under no obligation to answer these questions.
I consent to be contacted throughout for additional support and the 12 months following its conclusion to contribute to service evaluation.

Progress results and information will be added to the Active Lifestyle database and sent back to the GP to be added to the patient record.

I also give permission for anonymous data to be shared with Public Health England, Universities and other relevant bodies in order to plan, develop and improve treatment services.
In signing this consent form, I confirm that I have read this information, understand what the Active Lifestyles Weight Management Programme entails and will ensure that I take responsibility for my own health whilst undergoing the programme.

Privacy Notice

Sefton Council has developed a privacy notice in retrospect to Active Lifestyle’s programmes, which explains how we collect, process, hold and share your information; a copy of the privacy notice is available here

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Personal Details

About You