Register for The HOPE Centre services HOPE Centre Registration Data protectionYour 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 AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire 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*YesNoLone Parent*YesNoSmoker*YesNoPregnant*YesNoDue Date MM slash DD slash YYYY If you are pregnant, what is your due dateAre you registered with a Dentist?*YesNoHave you accessed dental services in the last year?*YesNoAre you entitled to claim any benefits?*YesNoAre you familiar with Job Centre Plus?*YesNoDo you have a disability and/or additional needs?*YesNoAdditional information If you answered Yes above, please give more details.Do you have your own transportation?*YesNoSecond Parent/Carer DetailsGender* Female Male Name* First Last Address* Street Address Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire 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*YesNoLone Parent*YesNoSmoker*YesNoPregnant*YesNoDue Date MM slash DD slash YYYY If you are pregnant, what is your due dateAre you registered with a Dentist?*YesNoHave you accessed dental services in the last year?*YesNoAre you entitled to claim any benefits?*YesNoAre you familiar with Job Centre Plus?*YesNoDo you have a disability and/or additional needs?*YesNoAdditional 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*FemaleMaleEthnicity* 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?*YesNoAccessed Dentist in the last year?*YesNoHave a dental appointment in the next 12 months?*YesNoChildren's Details (2)Name* First Last Date of Birth* MM slash DD slash YYYY Gender*FemaleMaleEthnicity* 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?*YesNoAccessed Dentist in the last year?*YesNoHave a dental appointment in the next 12 months?*YesNoConfirmation and dateConfirmation that the information you have entered is correct, plus today's date.Re-enter your name* First Last Today's date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PhotographyWe 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. NameThis field is for validation purposes and should be left unchanged.
