Active Me- RBKC Referral Form RBKC is working in partnership with The Running Charity to deliver ‘Active Me- RBKC’. This is a free weekly exercise programme based at Chelsea Theatre, for people over 18 living in the south of the borough who have no or very little experience of exercise and have some lived experience of mental health issues. Participation is by referral only and participants should be on benefits or on a low income. Priority will be given to homeless people or sofa surfers, people affected by the Pandemic, SEN clients, care leavers and refugees or asylum seekers. Participants must be over 18 years of age and living in one of the following wards: Abingdon, Queens Gate, Earls Court, Redcliffe, Courtfield, Brompton and Hans Town, Stanley, Chelsea Riverside and Royal Hospital. Referrer Details Name Organisation Position Best contact number Email address Applicant Details Name Post code Contact Number Email address Applicant Equalities Monitoring Sex Male ☐ If self-described, please state Female ☐ Age: 18-21 ☐ 22-30 ☐ Disability or other impairment: If yes, please describe disability or impairment Prefer to self-describe ☐ _______________________________________ 31-40 ☐ 41-50 ☐ 51-60 ☐ 61-70 ☐ Yes ☐ No ☐ Over 70 ☐ ______________________________________________ Applicant Ethnicity Asian/ Asian British Pakistani ☐ Indian ☐ Bangladeshi ☐ Black African/ Caribbean/ Black British Mixed Multiple Ethnic Groups African ☐ Somali ☐ Caribbean ☐ White and Black Caribbean ☐ White and Asian ☐ White and Asian ☐ White English/ Welsh Scottish/ N Irish/ British Moroccan Arab ☐ Irish ☐ Gypsy or ☐ Irish Traveller Other ☐ European ☐ Other Arab ☐ Filipino ☐ Any ☐ Other Ethnic group Other Ethnic Group Form continued on next page Chinese ☐ Other ☐ Asian Background ☐ Any other Black Background Any other Mixed background ☐ Other ☐ White Background Prefer ☐ not to state Active Me- RBKC Referral Form Does or is the participant? (Please tick all that apply) - Have no or very little experience of exercise Have lived experience of mental health issues Receive benefits or is on a low income A care leaver Been adversely affected by the Coronavirus Pandemic Have experience of homelessness or sofa surfing A Special Educational Needs (SEN) client An asylum seeker or refugee ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Please describe briefly why the referral is being made and how the participant will benefit from the Active Me programme? FOR COMPLETION BY REFERRING OFFICER All information will be handled in line with the Data Protection Act 2018 and the General Data Protection Regulation. The personal information used on this form will be handled by the Royal Borough of Kensington and Chelsea and will be shared with The Running Charity. It will also be used by the council to monitor course participants for equalities monitoring purposes. I will ensure that the person being referred is aware of the privacy notice and how their information is used. The privacy notice can be seen here. Fair Processing Notice | Royal Borough of Kensington and Chelsea ( Name: Date: Please send completed forms to Michael Frean, Community Participation Officer: by September 29th For queries please call 07970 030475

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