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Football in the Community
Mission and Values
Safeguarding and Governance
The Portland Centre
CARE Referral Form
Date of birth
Please list your medications
Please list any side effects
Limited range of movement
Depression and/or anxiety
Do you have any physical limitations?
Do you have any future cancer treatments planned?
Do you have any other medical conditions we should be aware of?
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Other Ethnic Group
Rather not say
Emergency Contact Details
Relationship to CARE participant
Contact phone number
Address (if different to participant)
Self-Referral Declaration (pre and during treatment): If I am receiving, or about to receive any of the following treatments: chemotherapy, radiotherapy, targeted therapy, hormonal therapy or surgery – I will consult with my clinical specialist nurse specialist prior to starting the physical activity programme. Should there be something that affects my ability to exercise or I have a change in medication, I will inform the instructor immediately and stop exercising if necessary.
Data Protection: We keep your records confidentially and securely. From time to time, our partners ask for information for monitoring & evaluation purposes to help us improve our service. Please tick this box if you consent to this.
Filming and Photo Consent: I understand that from time to time, photographs or filming will be taken during the CARE sessions. All such photography and filming will be carried out by a Notts County FITC-approved person and used to promote the CARE programme. Please tick this box if you consent to this.