Healthy Me Referral Form

  1. To be Eligible for this Programme
  • Child must be between the ages of 7 and 11 years.
  • Child’s body mass must be above the 91st centile for their age unless discussed with Healthy Me coordinator.
  • Child must be resident or attending school within the Wiltshire local authority borders.
  • Family are motivated to make a change to your lifestyle to improve their wellbeing.
  • Family must be able to attend every session over the 10 weeks with your child.
  • Family must all be able to work and interact in a group environment.
  • There are no underlying medical reasons for thechild that would stop them from attending.
  1. Details

Child’s Name (First, Surname)
Child’s Date of Birth (DD/MM/YY)
Child’s Gender
Child’s Ethnicity
Child’s First Language
Child’s School & Year Group
Child’s Height in cm (if known)
Child’s Weight in kg (if known)
Are there any reasons that you feel may effect the child’s participation (e.g. physical, social, medical, learning difficulties, any behaviour triggers). This information will enable us to make the delivery of the sessions appropriate.
Parent/ Carer Name attending the programme
Relationship to Child
Home Telephone Number
Mobile Telephone Number
Email
Home Address inc. Postcode
Emergency Contact during programme time (Name, Telephone Number)
Family GP (Dr’s Name, Surgery)
Do you give permission for us to contact your GP if required? / YES  NO 
Are there likely to be any other siblings attending with you to the programme. If so, can you specify their names and their ages
How did you hear about Healthy Me?
  1. ‘Parent/ Guardian/ Carer’ Physical Activity Readiness Questionairre (PAR-Q)

As part of the Healthy Me programme, parents will be expected to be involved in the physical activity sessions with your child as well as the learning. This may involve game type activities, walking, swimming, dancing and much more at a moderate level of intensity. Although physical activity is fun, safe and great for your health, some people may need to check with their GP before becoming more active. Please complete the questionnaire for you below and be honest with your answers. Tick YES or NO. If you answer YES to one or more of the questions, you should check with your GP to clarify that it is safe to participate in physical activity first.

  1. Data Protection and Sharing Information

The information provided on this form will be held by Wiltshire Council and used by us to compile and administer Wiltshire Council databases. If you have questions regarding the processing of personal data or you wish to see your personal data please contact or The Corporate Information Team, County Hall, Bythesea Road, Trowbridge, BA14 8JN.

  1. Your Commitment

Although this programme is free to the family, it is very important that they stay committed to the Healthy Me programme for the duration of the course. To get the best out of the programme, families should make every effort to support their child over the 10 weeks, ensuring they get to the sessions on time, encourage them to practice what they’ve learned each week, motivate them to engage in the physical activity, promote healthy eating and physical activity at home and at school, and feedback to the Healthy Me team what great progress their child makes. In essence, be positive, stay positive!

  1. Disclaimer

All the sessions offered are research based and contain up to date references to relevant research and literature. The leaders will inform participants to the best of their ability; however neither the leadersnor Wiltshire Council can accept responsibility for how this information is utilised or interpreted. Each individual accepts responsibility for their own learning, for seeking clarity on issues they don’t understand and for seeking further guidance and support on issues which remain confusing. We cannot guarantee weight loss and certainly do not advise this for children, but will work alongside participants and their families, to encourage lifestyle changes and help them achieve their chosen goals.

Participants, who are already seeking support and special dietary advice from dieticians or nutritionists, must continue to do so. Families with a social worker must inform them of your involvement into the Healthy Me programme, so that they can also support you to make changes to your lifestyle. Leaders are trained only to deliver the contents of the Healthy Me programme and cannot assist in areas outside their remit of this programme.

  1. Your Consent

By signing this document, you are agreeing to the following:

  • The child is eligible for the programme (section 1)
  • ALL boxes are completed for the child’s details (section 2)
  • Parent PAR-Q is completed (section 3)
  • Family agree to your personal data being stored by Wiltshire Council (section 4)
  • Family are committed to the programme (section 5)
  • Family have read and understood the disclaimer (section 6)

SIGNED (Parent/ Guardian):______

PRINT NAME:______

DATE:______

  1. What to do now

Once you have signed the above, send the form back to the Healthy Me team for processing to:

Mike Rose

Healthy Me Co-ordinator

Health & Physical Activity

Wiltshire Council

County Hall

Bythesea Road

Trowbridge

Wiltshire

BA14 8JN

Alternatively, you can email it to

Any questions or concerns can be raised before the course starts, by contacting Mike on 01225 716674, or text 07342 066847.