Parent Request for Support Form
Please use this form if you would like to request support from our Family Support Team at Bushy Leaze. 
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Full Name: *
Contact Number: *
Email: *
Address:  *
Baby/ Child's Name and DOB: *
What would you like support with? (If you are completing for Baby Massage, please select one that applies best)  *
Required
Is there any particular group you'd like to attend?  *
Required
Any other comments:
I declare that all information I have provided is true to my knowledge. By registering these details, I understand that the information will be held confidentially on the Bushy Leaze database and only shared with partner organisations such as health services and children’s agencies, for the purpose of contacting families to provide appropriate and timely services, evaluate service provision and for statistical analysis. 

In accordance with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018, any confidential information regarding your family will not be passed onto organisations outside of Children's Services partners, as mentioned above, without your consent, unless it is of a Child Protection nature, in which case information will be shared with appropriate agencies. 

I have read and understood the above and give my consent for Bushy Leaze Children and Families Centre to store the information in this form and any further information provided.   
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