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Be Buckfastleigh Membership Form
By filling out this form you will be applying for a Be Buckfastleigh Membership.
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The Information you provide here will be used for monitoring and evaluation purposes. We may share aggregated data with our funders, research partners and trusted third parties to evaluate our projects and participation, and to develop new services. When you join Be Buckfastleigh, you are agreeing to be added to our mailing list – which we will use to update you with opportunities and events at Be Buckfastleigh, and to let you know of anything important relating to your membership
Please fill out a form for each member of your household.
Personal Information
First Name
*
Your answer
Last Name
*
Your answer
Postcode
*
Your answer
E-mail
Your answer
Telephone number
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Do you consent to Be Buckfastleigh using any photos or videos that they have of you?
*
Yes
No
Which Be Buckfastleigh activities are you interested in?
*
Hello Summer Programme
Be Active
Cycling
Food related
Finance help
Training
Required
Are you on income related benefits?
*
Yes
No
Do you have any disabilities?
*
Yes
No
Do you have any health issues?
*
Yes
No
Do you have any barriers that might stop you from taking part in activities (such as health issues, lack of funds, etc)?
*
Yes
No
Required
If you answered 'yes' to having barriers, what are these barriers?
Your answer
ALL THE QUESTIONS BELOW APPLY ONLY FOR CHILDREN'S MEMBERSHIP APPLICATIONS! If you are an adult applying for a membership, please choose N/A for each required answer, or skip the following quesions. Thank you!
What school or education setting do you go to?
*
Choose
Buckfastleigh Primary
St Mary's Primary
Home Educated
St John's Church of England Primary
The Grove
South Devon Steiner School
Park School
Landscove Primary
Berry Pomeroy Primary
Ashburton Primary School
South Dartmoor Community College
KEVICC
Other
N/A
If you answered 'other' above, please tell us where below
Your answer
Emergency Contact Details
Your answer
Do you give consent for Emergency First Aid?
YES
NO
N/A
Do you receive benefit related free school meals?
*
Yes
No
N/A
Do you have any special education needs?
*
Yes
No
N/A
Do you have any disabilities?
*
Yes
No
N/A
Are you a child in the care system (living with foster parents, in a residential children's home, etc)
*
Yes
No
N/A
Are you a young carer (a young carer is someone aged 25 and under who cares for a friend or family member who, due to illness, disability, a mental health problem, or an addiction, can not cope without their support)?
*
Yes
No
N/A
Do you have an Early Help Plan?
*
Yes
No
N/A
Do you have a Child Protection Plan?
*
Yes
No
N/A
Do you have an EHC Plan?
*
Yes
No
N/A
Do you have low attendance at school, or are at risk of being excluded?
*
Yes
No
N/A
Are you living in a high area of deprivation, or your family is on a low income?
*
Yes
No
N/A
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