NEW 2019 Intentional Health Member Consent Form

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Please enter the email address for each member. You will recieve a copy of this completed form for your records. If you are a coach completing this form on behalf of a members who has not given their email address, please use your email instead.

Email *

As a member of an Intentional Health group, I fully understand and accept full responsibility that: *

Yes

1. My participation in the Intentional Health programme is entirely voluntary.

2. Any advice, suggestions or guidance provided as part of the programme is not specialist advice and I am solely responsible for any actions I take as a consequence. If I am in any doubt I understand it is my responsibility to go to my GP for further advice.

3. I agree to let the information I give to Intentional Health be used for research purposes. I understand if this were to happen my data would be stored securely, be used for research purposes only and if results from this research were to be published my anonymity would be preserved. If at a later date I wanted, I could ask for my data to not be used in research without any prejudice or disadvantage.

4. I agree to any photographs or video footage be used only internally for Intentional Health coaches, staff, angels and trustees.

5. I agree to any photographs or video footage or my story be publicly shared, including via social media, to promote Intentional Health programmes

6. I agree that any feedback I give can be used to inform and promote future programmes.

7. I have a long-term illness, health problem or disability which limits my daily activities or the work I do (Including problems due to old age).

8. I give consent for my personal information to be handled in accordance with Intentional Health’s Data Privacy Policy, a copy of which can be supplied to me on request.

9. I give my consent for Intentional Health HQ to contact me by the email address below to receive feedback as to my ongoing progress from data collected before and after the programme.

Yes

1. My participation in the Intentional Health programme is entirely voluntary.

4. I agree to any photographs or video footage be used only internally for Intentional Health coaches, staff, angels and trustees.

5. I agree to any photographs or video footage or my story be publicly shared, including via social media, to promote Intentional Health programmes

6. I agree that any feedback I give can be used to inform and promote future programmes.

7. I have a long-term illness, health problem or disability which limits my daily activities or the work I do (Including problems due to old age).

8. I give consent for my personal information to be handled in accordance with Intentional Health’s Data Privacy Policy, a copy of which can be supplied to me on request.

9. I give my consent for Intentional Health HQ to contact me by the email address below to receive feedback as to my ongoing progress from data collected before and after the programme.

Full Name (or initials)

Signed

By completing your name in this box you are agreeing as if you have signed in person. If you are the coach filling this in online please keep the paper copy of this consent form safe and enter your name in this box to confirm that you have entered the information correctly. For full details of our Data Privacy Policy see https://www.intentionalhealth.uk/privacy-policy/

Programme ID & Member No

Date

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