Referral form – Community Classes

Please use this form to refer participants for a fully funded 6 week course in our community classes. If participants attend all sessions, we can discuss whether they would like to attend additional course

Criteria: Participants must

• have a socio-economic barrier to affording classes
• be open to group exercise
• benefit from increasing their mobility and/or being more social in the community.

Referrer Name *

First

Last

Referrer Email *

Referrer Contact Number *

Name of Organisation *

Which class would you like to refer the participant to? *

• Keep Moving Teesside! – The Glebe Community Centre, Norton, Mondays 3:15-4:15pm
• Keep Moving Teesside! – St Augustines Church Hall, Kirkby, Great Broughton, Mondays 1:30-2:30pm
• Keep Moving Teesside! – St Mary’s Church Hall, Nunthorpe, Wednesdays 1:30-2:30pm
• Keep Moving Teesside! – Holy Name of Mary Church Hall, Linthorpe, Thursdays 1:30-2:30pm
• Keep Moving Teesside! – The Rings Community Hub, Ingleby Barwick, Fridays 1:30-2:30pm
• Other

If referring using ‘other’ please email us the class you wish to refer to, so we can update on our records.

Participants name *

Participants phone number *

Participants email (if applicable)

Has the participant consented to the referral? *

• Yes
• No

Participants age

Participants Ethnicity

Participants 1st part of postcode (EG- TS3, TS5, TS10)

Does the participant have any long term health conditions or progressive conditions? If so, please note below. *

E.G. Heart Condition Respiratory Condition Diabetes High Blood Pressure Progressive illness (Cancer, HIV, Parkinson’s) Vision Impairment Hearing Impairment Mental Health Condition

Does the participant have any Muscular Skeletal Kinetic conditions? If so, please note below. *

E.G. Osteoarthritis Inflammatory Arthritis Fibromyalgia Trauma (tendonitis, broken bones, injury etc) Long term pain >3 months Other MSK condition

Please explain why the participant would benefit from funded classes. *

Are there any known risks to the participant or others? If so please state. *

Does the participant have any physical or mental health diagnoses? If so please list below. *

Does the participant have any specific needs when attending class? (Wheelchair/walker access, medication incase of emergency etc). *

Does the participant drink alcohol, take recreational drugs or non prescribed medicines? If so please state below. *

Please note all participants must abstain from alcohol and substances 24 hours before class for the purpose of health and safety. If an individual attends class and appears inebriated we will unfortunately have to decline entry.

Will the participant have a carer supporting them in classes? (Carers are welcome to attend without charge). *

• Yes
• No

Please use this box if there is any additional information you would like us to know.

Submit