Base 51 Membership Form
You need to fill in this form to be able to access Base 51 services.

Privacy Notice - Data Protection and Confidentiality Statement  

The information that you provide on this form will be used by Base 51 in a number of ways. Please read each section of this form carefully so that you understand what information and data we will store about you, and how this will be used. If you are not sure what things mean, please talk to a member of staff before completing this form who will explain it for you.  

 

Base 51 is fully committed to protecting your data and complies with the General Data Protection Regulations (GDPR). This is a piece of legislation in place across the UK and Europe designed to make sure that your rights as an individual are protected, if you would like to know more about this please ask a member of staff.   

 

We store your data on secure systems and only authorised workers have access to look at this information.  

 

As a charity, Base 51 has to create reports about how well we are meeting our aims and objectives, and this is called “monitoring”. Any information we gather from this form to use for our monitoring reports is always anonymous. This means that you, as an individual, cannot be identified from these reports.  

 

All Base 51 services are confidential. This means that we will not give out information about you. It is important for you to understand that sometimes we might have to break this confidentiality. If we think that there is any risk of harm to you, or to anyone else, we might have to tell other agencies (like your parent/carer, the Police, Social Care or the Child and Adolescent Mental Health Service) to ensure the safety of you or other people. We have a legal obligation to do this (this means that the law says that there are certain things we have to do to keep people safe), but wherever possible we will talk to you about this first so that you know what information we are sharing.  

 

You have the right to ask us to stop using your data, and in some cases to have it deleted completely. If you would like to do this, please talk to a member of staff who will give you more information.  

 

Key words 

This form uses some words that you might not have heard before. Here is what we mean: 

  • Data – this is the piece of information you are providing. For example, your date of birth is one piece of data, and your address is another piece of data.    

  • Comply (or complies) – this means to follow all of the rules or laws that are in place  

  • Legislation – this is another name for a group of laws about a particular subject   

  • Monitoring – the reports and information that Base 51 create to show that the organisation is meeting its aims and objectives 

  • Anonymous – not identified by name or any other information that would make it clear who you are 

  • Processing – to use the data in any way, for example to add it to a system or to use it as part of a report 

  • Mandatory – this means that we must have the information in order to carry out our work, or to provide you support  

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Section 1: Name and age - this information is mandatory

The information in this section is used so that we can work with you in a productive way, and make sure that you are in the right age range to access our service. 

First Name *
Last Name *
Age *
Date of Birth *
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Section 2: Contact Details - this information is mandatory

Your contact details will only be used if we need to get in touch with you. One example might be to make sure you are safe. The area of Nottingham that you live in is also used in our anonymous monitoring information. 

Address *
Post Code *
Email Address *
Mobile Phone Number *

Section 3: Emergency Contact - this information is mandatory

We need to have someone to contact in the case of an emergency – this is to keep you safe. If you are under 18 this must be a parent or carer. 

Contact Name *
Relationship to you *
Contact telephone number *
Section 4: Information about medical conditions or disabilities - this information is mandatory

We need to know about any medical conditions or disabilities you have, to make sure that you have any support you might need to access our services. We might also need to put plans in place to help you leave the building in an emergency, for example if the fire alarm sounds (these are called Personal Emergency Evacuation Plans).

 

We also provide anonymous monitoring information about the number of members who have a medical condition or disability as we want to make sure that we are fair and accessible to everyone. 

Do you consider yourself to be disabled? *
Do you have any medical conditions you would like us to be aware of? *
If you answered yes to either question, please give us further information

Section 5: Sensitive Personal Data - this information is mandatory

The following questions are used in our anonymous monitoring reports. This information is very useful in making sure that Base 51 is creating equal opportunities for all, as well as helping us to look at what kind of sessions and activities we might run for members.

 

This information will not be used to influence the way we work with you directly and will not impact whether or not you can access Base 51. 

 

We need your explicit consent to process and store this data. This means you have to provide your clear permission. 

What is your gender identity? *
Are you transgender? *
I provide my consent for this data to be processed 
 *
Required
What is your Sexual Orientation *
I provide my consent for this data to be processed 
 *
Required
Race/Ethnic Origin *
Required
I provide my consent for this data to be processed 
 *
Required
Section 6: Where did you hear about Base 51? - this information is mandatory

We use this information in our anonymous reporting, and it helps us to understand how we can increase the number of young people using Base 51. 

Please give details of how you heard about Base 51?

 *

Other things you need to know about being a member of Base 51

There are lots of facilities that you can access once you become a member of Base 51. Once you have your membership card you can come to any of the sessions open to your age range.

 

You need to bring your membership card with you every time you come, or you will not be able to enter the building. If you lose your membership card, it will cost you £1.00 for a replacement.

 

Every time you enter or leave the building, make sure you place your card against the black reader next to the door at reception. This is very important because it tells us who is in the building for safety and security purposes. We also use data from this system to show how many people are using Base 51, but this is always anonymous.


Code of Conduct


By becoming a member of Base 51 you are agreeing to our Code of Conduct. A member of staff will go through this with you in more detail, but the key points are:

·         There should be mutual respect between staff and young people.

·         No inappropriate sexual behaviour.

·         The making of cigarettes, smoking and the use of vapes is not allowed on the premises.

·         Drugs and alcohol are not allowed on the premises.

·         The buying, selling or exchanging of good is not allowed.

·         Offensive, discriminative and threatening behaviour is not tolerated.

·         Staff and young people should keep Base 51 clean and tidy and be responsible for your belongings.

·         Parents and carers should supervise their children at all times.

·         Any concerns or worries please speak to a member of staff.

If you break any of these rules you may be asked to leave the session or be suspended from accessing Base 51.


By signing this form, you are accepting that you understand how we will use the data you have provided. If you are not sure about any part of this form, please talk to a member of staff before signing the form.
Typing your name will be counted as an electronic signature.
Your Name *
Date of filling in form *
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