Family Hub membership form

Parent/Carer 1
Title
If other, please state
Forename
Surname
Known as
Gender
MaleFemaleNon-binaryPrefer to self-describePrefer to self-describe
Date of birth
Ethnicity
Preferred language
Nationality
Address
Postcode
Mobile number
Telephone number
Email address
Are you employed or in training?
YesNo
Are you a smoker?
YesNo
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Relationship to 2nd parent/carer

Parent/Carer 2
Title
If other, please state
Forename
Surname
Known as
Gender
MaleFemaleNon-binaryPrefer to self-describePrefer to self-describe
Date of birth
Ethnicity
Preferred language
Nationality
Address
Postcode
Mobile number
Telephone number
Email address
Are you employed or in training?
YesNo
Are you a smoker?
YesNo
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Relationship to 1st parent/carer

Child 1
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child 2
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child 3
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child 4
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Ethnicity
Additional needs (SEN support/EHCP)
Relationship to parent/carer 2
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child 5
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child 6
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child 7
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child 8
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child 9
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo
Add another child
YesNo

Child ten
Name

First name

Last name
Address
Postcode
Date of birth/Estimated delivery date
Ethnicity
Nationality
Gender at birth
MaleFemaleNon-binaryPrefer to self-describe
Relationship to parent/carer 1
Relationship to parent/carer 2
Additional needs (SEN support/EHCP)
Are you registered with a dentist?
YesNo
Are you registered with a GP?
YesNo
Are you taking up the 2 yr / 3-4 yr childcare funding?
YesNo

Agencies in Blackpool are working together to meet the needs of families and provide the support that they may need at any time. We therefore need to obtain your consent to:
• Membership with the Family Hub
• Use and store your information so that we can contact you with regards to upcoming events by Family Hubs and their partners
• Record your attendance at activities by Family Hub and their partners
To discuss and signpost you to support if you feel that this is needed for you and your family.
For further details about how Blackpool Council uses your personal information please see below.
Where did you hear about us

e.g. School, health visitor, nursery, BetterStart?
What is your preferred method of contact
Name

First name

Last name
Date
You can withdraw consent at any time by talking to your worker or writing to the data protection officer
Privacy notice
Who is responsible for your data

Blackpool Council is the Data Controller for the personal information you have provided in this form. The council's data protection officer can be contacted at Dataprotectionofficer@blackpool.gov.uk or by writing to Data protection officer, PO Box 4, Blackpool, FY1 1NA.
Why do we collect your information?

The Early Help and Support Service provides and co-ordinates a range of services for children and their families designed to support them to grow, thrive and achieve This could be a group or activity in or linked to one of our Family Hubs, like a parenting course, a stay and play session or a health appointment. It could also be a family or support worker who works with families in their own home, developing an understanding of any support they need and developing a plan to make sure they get the right help.

We keep your personal information because we want to know who you are. Blackpool Council want to make sure that all families are cared for and have the best outcomes. It helps us to know what help you might need. If we do not have your personal data then you could miss out the things that we could do for you.
What is our lawful basis?
For Early Help and Support, we use a number of different lawful basis to allow us to collect and use your personal information dependant on what service you will be accessing;

Some services such as Family Support will use the following legal basis;

It is necessary for the Council to perform a task in the public interest or whilst conducting its official functions, and the task or function has a clear basis in law.

The relevant statute that underpins the processing is:
- Section 1 of The Childcare Act 2006
- Children Act 2004 Section 10
- Part 3 of the Children and Families Act 2014
- Working Together to Safeguard Children July 2018 Chapter 1
For other services such as applying for membership with the family hub, we will seek you explicit consent.

For the collection of special category data we use the following conditions for processing:

(a) Explicit consent

(h) Health or social care
What types of information do we collect?
The information we hold may include:
- Personal data (such as name, date of birth, address, and telephone number ethnicity, gender,).
- Information about your family history and your lived experience, your health, finance information, religion or who your friends are.
- Personal information regarding dependent children, school or nursery they attend and how often they attend, additional needs including SEND and some medical conditions.
- Assessment of need and agreed actions to support unmet needs
- Details of any risks to professionals in order to safeguard the workforce
- Attendance at activities and services delivered by Blackpool Council and partners.
We will also collect relevant information from the agencies you consent to help with your families’ assessment and plan or to notify you of events or activities which we think that you may be interested in.
Who do we share your information with?
In some circumstances, we will need to share information about you; For example:
- With internal Blackpool Council departments (ie. providing education, health and support services)
- With Lancashire County Council specifically for Claim applications
- Early Help Partners who have requested this information with your consent to provide your family with support (for example Better Start, Education establishments, Voluntary, Community and Faith Sectors).
- Anonymised data will be shared with Government departments - Department for Work and Pensions, Ministry of Housing, Communities and Local Government, Department for Education.
- There are times when we have to share information about you if you are at risk from others or you are a risk to others. .
We do not transfer your information to a third country (that is a country outside of the EEA).
Your rights

You have a number of rights relating to the processing of your information, including the right to access the information we hold about you, the right to erasure (the right to be forgotten) and the right to have inaccurate data corrected.

More information about your rights can be found on the council's website the Information Commissioner's website or you can ask for information about these rights from the council's data protection officer.
Complaints

If you are not happy with how the council has handled your personal information, you can complain to us to give us the opportunity to resolve this with you.

You should contact the data protection officer if you have a complaint.

Alternatively, you can complain to the Information Commissioner. Their contact details are: Information Commissioner's Office, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF. Telephone: 0303 123 113 or by email to casework@ico.org.uk

Family Hub membership form

Additional information