Referral form – Yoga for Older Adults Course in Linthorpe

Please use this form to refer participants for a fully funded 6 week course in our community class in Linthorpe.

Time: Mondays 9:15-10:15am
Location: Holy Name of Mary Church Hall, The Avenue, Linthorpe, Middlesbrough TS5 6QT 

If participants attend all sessions, we can discuss whether they would like to attend additional courses.

Criteria: Participants must

• be aged 50+
• 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 *

Participants name *

Participants phone number *

Participants email (if applicable)

Has the participant consented to the referral? *

• Yes
• No

Is the participant over 50? *

• Yes
• No

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 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