Register for The HOPE Centre services

HOPE Centre Registration

Data protection
Your information is confidential and covered by the Data Protection Act, 1998. No personal details will be shared without your permission. The information is used only to provide statistical data in order to support the work of the HOPE Children's Centre and to secure funding applications. We will ask all families to complete a form each year to ensure our information is up to date.
Where did you hear about HOPE?*
- HOPE Website
- Friends/family
- Herefordshire Council
- Health Services (e.g. GP/Midwife/Health Visitor)
First Parent/Carer Details
(If you are a lone parent, please use the "Second Parent/Carer" section to give a name and phone number of someone who can act as an emergency contact)
Gender*
- Female
- Male
Name*
First Last
Address*
Street Address Address Line 2 City County Post Code
Mobile Number*
Home Telephone*
Email*
Enter Email Confirm Email

Your email address will be used to keep you informted about news & events at HOPE, including groups and training information.
HOPE information emails
- Do not send information emails from HOPE
Tick the box above if you do not want to receive information emails from HOPE.
Date of Birth*
Month
Day
Year
Ethnicity*
- 1 - White (British)
- 2 - White (Irish)
- 3 - White (Other)
- 4 - White (Eastern Europe)
- 5 - White (Western Europe)
- 6 - Mixed (White / Black Carribbean)
- 7 - Mixed (White / Black African)
- 8 - Mixed (White / Asian)
- 9 - Mixed (Other)
- 10 - Asian (Indian)
- 11 - Asian (Pakistani)
- 12 - Asian (Bangladeshi)
- 13 - Black (British)
- 14 - Black (Carribbean)
- 15 - Black (African)
- 16 - Black (Other)
- 17 - Chinese
- 18 - Traveller
- 19 - Other
- 20 - Origin not declared
First language spoken*
Country of birth*
Parent*
Lone Parent*
Smoker*
Pregnant*
Due Date
MM slash DD slash YYYY

If you are pregnant, what is your due date
Are you registered with a Dentist?*
Have you accessed dental services in the last year?*
Are you entitled to claim any benefits?*
Are you familiar with Job Centre Plus?*
Do you have a disability and/or additional needs?*
Additional information

If you answered Yes above, please give more details.
Do you have your own transportation?*
Second Parent/Carer Details
Gender*
- Female
- Male
Name*
First Last
Address*
Street Address Address Line 2 City County Post Code
Mobile Number*
Home Telephone*
Email*
Enter Email Confirm Email

Your email address will be used to keep you informted about news & events at HOPE, including groups and training information.
HOPE information emails
- Do not send information emails from HOPE
Tick the box above if you do not want to receive information emails from HOPE.
Date of Birth*
Month
Day
Year
Ethnicity*
- 1 - White (British)
- 2 - White (Irish)
- 3 - White (Other)
- 4 - White (Eastern Europe)
- 5 - White (Western Europe)
- 6 - Mixed (White / Black Carribbean)
- 7 - Mixed (White / Black African)
- 8 - Mixed (White / Asian)
- 9 - Mixed (Other)
- 10 - Asian (Indian)
- 11 - Asian (Pakistani)
- 12 - Asian (Bangladeshi)
- 13 - Black (British)
- 14 - Black (Carribbean)
- 15 - Black (African)
- 16 - Black (Other)
- 17 - Chinese
- 18 - Traveller
- 19 - Other
- 20 - Origin not declared
First language spoken*
Country of birth*
Parent*
Lone Parent*
Smoker*
Pregnant*
Due Date
MM slash DD slash YYYY

If you are pregnant, what is your due date
Are you registered with a Dentist?*
Have you accessed dental services in the last year?*
Are you entitled to claim any benefits?*
Are you familiar with Job Centre Plus?*
Do you have a disability and/or additional needs?*
Additional information

If you answered Yes above, please give more details.
Children's Details (1)
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Ethnicity*
- 1 - White (British)
- 2 - White (Irish)
- 3 - White (Other)
- 4 - White (Eastern Europe)
- 5 - White (Western Europe)
- 6 - Mixed (White / Black Carribbean)
- 7 - Mixed (White / Black African)
- 8 - Mixed (White / Asian)
- 9 - Mixed (Other)
- 10 - Asian (Indian)
- 11 - Asian (Pakistani)
- 12 - Asian (Bangladeshi)
- 13 - Black (British)
- 14 - Black (Carribbean)
- 15 - Black (African)
- 16 - Black (Other)
- 17 - Chinese
- 18 - Traveller
- 19 - Other
- 20 - Origin not declared
Registered with a Dentist?*
Accessed Dentist in the last year?*
Have a dental appointment in the next 12 months?*
Children's Details (2)
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Ethnicity*
- 1 - White (British)
- 2 - White (Irish)
- 3 - White (Other)
- 4 - White (Eastern Europe)
- 5 - White (Western Europe)
- 6 - Mixed (White / Black Carribbean)
- 7 - Mixed (White / Black African)
- 8 - Mixed (White / Asian)
- 9 - Mixed (Other)
- 10 - Asian (Indian)
- 11 - Asian (Pakistani)
- 12 - Asian (Bangladeshi)
- 13 - Black (British)
- 14 - Black (Carribbean)
- 15 - Black (African)
- 16 - Black (Other)
- 17 - Chinese
- 18 - Traveller
- 19 - Other
- 20 - Origin not declared
Registered with a Dentist?*
Accessed Dentist in the last year?*
Have a dental appointment in the next 12 months?*
Confirmation and date
Confirmation that the information you have entered is correct, plus today's date.
Re-enter your name*
First Last
Today's date*
Photography
We may need to take photographs of your child or children during activities that may be used for promoting The HOPE Centre's activites on displays, publications, and on our website.
Photography
- Tick this box if you would prefer us NOT to photograph your child/children.
Comments
This field is for validation purposes and should be left unchanged.

HOPE Centre Registration

Data protection

First Parent/Carer Details

Second Parent/Carer Details

Children's Details (1)

Children's Details (2)

Confirmation and date

Photography