Membership No:
Date completed:
Staff Name:
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For office use only
Membership Form
Your details will be kept on a database so that we can contact you (and others in the event of an emergency) and so that we can report anonymously to funders. Your information is kept confidential in accordance with data protection legislation. No personal information is shared with others without your explicit permission.
PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS. THANK YOU.
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Ethnicity (Please tick ONE only)
White
Other Ethnic Group
Asian/Asian British/Chinese
Black/African/Caribbean/Black British
Mixed/Multiple Ethnic Groups
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What is the ONE most important thing you would like to get from Claremont Membership? (Please tick ONE only)
What activity are you most interested in
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| Do you live alone? |
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| Are you a Registered Carer? |
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| Do you regularly help or support a family member or friend (eg -- help with the food shopping)? |
Any additional information:
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| Are you registered disabled? |
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| Are you retired? |
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| Are there any physical or mental health issues you want to tell us about? |
Which of these categories describes your approximate income last month?
As a small charity, Claremont relies on funding from many different places, this question helps us continue to provide our activities, as well as understand your situation better. The full State pension is currently £185/week or about £800/month.
Do you receive support or help (formally or informally) from any of the following? (Please tick all that apply)
Well-Being Scale (WEMWBS*)
Below are some statements about feelings and thoughts. Please tick the box that best describes your experience of each OVER THE LAST 2 WEEKS:
| STATEMENTS | None of the time | Rarely | Some of the time | Often | All of the time |
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| I've been feeling optimistic about the future | |||||
| I've been feeling useful | |||||
| I've been feeling relaxed | |||||
| I've been feeling interested in other people | |||||
| I've had energy to spare | |||||
| I've been dealing with problems well | |||||
| I've been thinking clearly | |||||
| I've been feeling good about myself | |||||
| I've been feeling close to other people | |||||
| I've been feeling confident | |||||
| I've been able to make up my own mind about things | |||||
| I've been feeling loved | |||||
| I've been interested in new things | |||||
| I've been feeling cheerful |
*Warwick-Edinburgh Mental Well-Being Scale (WEMWBS)
© NHS Health Scotland, University of Warwick and University of Edinburgh, 2006, all rights reserved
© NHS Health Scotland, University of Warwick and University of Edinburgh, 2006, all rights reserved
Thanks and Welcome from the Claremont Team
CLAREMONT PROJECT - PARQ FORM 2024
PLEASE READ AND COMPLETE THIS FORM CAREFULLY
| 1. A) Has the doctor ever said you have a heart condition? |
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| 1. B) If YES to the above question, have you been told you should ONLY do specific physical activity recommended by your doctor? |
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1. C) If YES to the above question/s, please provide details here: |
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| 2. Do you ever feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? |
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| 3. In the past month have you had chest pain when you were not doing physical activity? |
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| 4. Do you lose balance because of dizziness? |
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| 5. Do you have asthma or any other respiratory problems? |
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| 6. Do you have a bone or joint problem that could be made worse by physical activity? (if yes give details below) |
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| 7. Do you have any medical condition that could be made worse by an increase in physical activity? (if yes give details below). |
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| 8. A) Are you recovering from any illness or surgery or is there any other reason why you should not do physical activity? |
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8. B) If you answered YES to the above question, please give details here: |
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9. Please provide details of any current medical conditions or diseases: |
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10. Please list all medications you are currently taking: |
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11. Please list all medical equipment you have here e.g., inhalers, even if you do not use them often: NB: Any prescribed inhalers need to be with you at all times.
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| If you answered YES to any of the questions above, you should seek further information from a medical professional before becoming physically active or engaging in a fitness appraisal. Claremont Project may require further information from you, or your doctor before you are cleared to partake in our physical exercise offerings. | ||
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If you answered NO to all of the questions above, you are ready to become more physically active. You are encouraged to start slowly and build up gradually - low to moderate intensity exercise, 3 - 5 days per week including aerobic and muscle strengthening exercises. If you have any temporary illnesses such as a cold or fever, it is best to wait until you feel better. If you have any medically related equipment, you must bring this with you to all physical sessions offered by the Claremont Project, including your first session and every session following this. This applies in all cases, even if you do not use this equipment often or usually have it to hand for exercising. During Claremont sessions, this must be kept in sight and clearly identifiable as belonging to you by your Tutor - e.g placed in your pocket or close to hand or under your chair. Please wear comfortable clothing and flat shoes. Please now read and sign the declaration below. |
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Declaration: I have read (or it has been read to me), understood and completed this form. I have answered Questions to my full satisfaction. I will inform the instructor of any new or unusual symptoms, changes to my medication, any new medically related equipment, results of any investigations or treatment. I agree to being contacted to discuss my physical activity and my GP being contacted if deemed necessary. I acknowledge that Claremont Project may retain a copy of this form for records, and it will be shared with the relevant Tutors as necessary. This will remain confidential, complying with applicable law. If you require the assent of a care provider, the care provider must also sign this form.
PRINT NAME:
DATE:
SIGNATURE:
SIGNATURE OF CARE PROVIDER (IF APPLICABLE):
24 -- 27 White Lion Street
London N1 9PD
Telephone: 02076898091
Email: amy@claremont-project.org
Code of Conduct
Claremont is committed to making our building an inclusive and welcoming community center and expects a high level of good conduct from our members, our employees, and from other center users and participants. Employees, members, and other users of the centre are required to treat each other with the utmost dignity and respect and follow the expectations of our Code of Conduct.
Our Expectations
- We do not tolerate any bullying, intimidation, violence, or threatening behavior.
- We do not tolerate racism, homophobia, obscene language, sexism, or harassment (including unwanted comments on physical appearance).
- We have a zero-tolerance policy on the misuse/abuse of drink and drugs. If a member of staff assesses someone to be under the influence of drink and/or drugs, they will be asked to leave the building.
- We expect users of the building and its facilities to respect our property and to use the building safely, taking responsibility for your actions.
- We expect people not to engage in any other behaviour that would be considered unacceptable by a Reasonable Person. Examples include:
- Dominating in groups/classes/social areas by being overly loud in voice or demanding undue attention in other ways (asking endless questions, ignoring facilitator instructions, talking over other people, etc).
- Engaging in lengthy conversations with other members, volunteers, or staff, without respecting the other person's time.
- Dressing inappropriately for a class having been told what is appropriate for that class.
- Displaying poor levels of personal hygiene, including particularly dirty and smelly clothes.
- Proselytising religious beliefs.
Claremont will:
- Uphold and promote equality, diversity, and inclusion.
- Promote the health, safety and wellbeing of people who use the centre.
Members who feel aggrieved by unacceptable behaviour, or are witness to such, are encouraged to report the matter to the CEO (Amy Pollard). Complaints will follow Claremont's published complaints procedure.
Claremont Project (Islington) Ltd: Terms & Conditions of Service
1. Organisation
Claremont Project (Islington) Ltd ("Claremont") is a company limited by guarantee (no. 03453945) and is registered as a charity with the Charity Commission (no. 1070611). Claremont is not a members' or proprietors' club.
2. Privacy Policy and Data Protection (GPDR)
Claremont provides a range of services to its customers and external organizations help Claremont with funding for these services. Due to the requirements of these organisations, participation in many of our services is restricted. These restrictions usually relate to a person's Borough residency, age, and/or income. For this reason, we ask participants to share with us various personal details. This enables us to keep classes at very low cost (or free in some cases). We also require members to complete a "Before" (on joining) and "After" (3-4 months later) Warwick Edinburgh Mental Well Being Scale form. The results of these forms are anonymised for reporting purposes and completion of both forms is a requirement of Claremont membership.
Participants are given an ID card and this is shown to the class facilitator before the start of Claremont classes or activities. This is a requirement of participation and ensures participants' eligibility and provides anonymised data for reporting to funders.
The legal basis for us collecting and processing this information is "Legitimate Interests". The processing of data collected is necessary for our legitimate interests or the legitimate interests of a third party, unless there is a good reason to protect the individual's personal data which overrides those legitimate interests. These interests include being able to contact you about classes you attend (cancellations or special arrangements, for example), tracking attendances which is necessary for us reporting to funders, fundraising, for managing and planning classes/activities, and for eligibility for any projects which have legitimate eligibility criteria. The data is also used to contact someone you name as an emergency contact, for assessing attendances in classes, changes in well-being, for informing emergency medical services of any relevant conditions if you need their help while at Claremont, and for assessing the quality and fair operation of our services.
Your personal details and attendance records are kept in a secure and encrypted database and Claremont is registered with the Information Commissioner's Office. Our Data Controller is Amy Pollard, CEO of Claremont, 24 White Lion St, London N1 9PD.
Claremont promises to respect your privacy and not to share any personal details about you with any other party unless required to do so by law or unless you have agreed and asked for Claremont to do so. Your personal details are removed from the active database once Claremont believes that you are unlikely to return to resume classes/activities. This is after 4 months or more of not attending. Your personal details will be completely deleted after one year of not attending.
You have various rights under data protection legislation, which includes being informed (as above) of our data use, to withdraw from this agreement at any time and have your personal details permanently deleted, to request a copy of your data, and to make a complaint to the Data Controller and/or to the Information Commissioner. Please be aware that should you decide to ask us to delete your personal data, we will not be able to continue providing you with our services.
3. Conduct
You are required to behave in an appropriate manner at all times while participating in Claremont services and/or being in the Claremont building. Inappropriate behaviour includes behaviour that is unlawful, harmful, threatening, unsafe, rude, abusive or otherwise socially unacceptable or which in the opinion of Claremont staff injures the character and reputation of Claremont. Claremont will exercise its discretion reasonably in deciding if you have behaved in an inappropriate manner. If you are dissatisfied with the decision made by Claremont's staff, you can request it is reviewed by Claremont's Chief Executive Officer and if you are still dissatisfied, you can write for a review of the decision by the Chair of Claremont's Board of Directors/trustees, whose decision will be final. During the review/appeal process, you may not continue to participate in Claremont activities. Claremont is a strictly non-smoking environment.
4. Provision of Services
Claremont will do its best to provide the services it advertises. However, sometimes it is not possible to run a class or activity (due to a class facilitator being ill or a hall being closed for maintenance or refurbishment, for example). Claremont will make best efforts to contact you ahead of time to warn you that the class is cancelled. However, Claremont shall not be liable for any expense you might incur coming to a class that has been cancelled. If in doubt (bad weather, for example), please call us first.
5. Photography
Claremont often takes photographs and videos of Claremont activities and those participating in them. This media is used in a variety of ways, including but not limited to: evaluation material for organisations funding our work; promotional material for advocacy, fundraising, and policy communications; educational material; archival records of projects. No financial compensation will be due to you as a participant for the use of this media, which may include photographs or film of you. The media taken may be held and used by Claremont, with the first and surnames of those featured, for as long as is reasonably necessary for the above purposes.
6. Liability
Claremont shall not be liable for any loss or damage caused to any property belonging to or brought into Claremont by you. Please take care of your belongings!
7. Variation of Terms & Conditions
These terms and conditions may be revised from time to time. If they are revised, we will post the revised version prominently on Claremont's notice boards. It is your responsibility to keep up-to-date with all such changes by checking the notice boards at Claremont.
I agree that by using Claremont's services I am agreeing to the above terms and conditions.
Name (PRINT):
Signature:
Date: