Move Forward Self-Referral

Preferred mode of contact *

Are you between the ages of 25 and 65? *

Are you currently in paid work of any kind, including any zero hours contracts?
*

Does you live in Social Housing? *

Declaration: The information provided in the form is, to the best of my
knowledge, accurate *
YesNo

Declaration: I am not in paid work of any kind, including any zero hours
contract. *
YesNo

Declaration: If I have ticked a ‘Prefer not to say’ option anywhere on this
form, I confirm that I am refusing consent for this information to be collected. *
YesNo

Declaration: I give permission for my personal details to be shared
with the partners who are signatories to the Information Sharing Agreement involved in the delivery of
this project. A copy of the information sharing Agreement can be found within the privacy policy here
https://www.activelancashire.org.uk/privacy-policy *
YesNo

Declaration: I understand that this information will be retained until at
least 31 December 2035 for evaluation purposes. After that time, it will be destroyed in a secure
manner. *
YesNo

Declaration: I may be contacted at any time to discuss my involvement in
the project *
YesNo

Declaration: I understand that the DLU, Government Internal Audit Agency,
statutory bodies and signatories to the Information Sharing Agreement may request to see this
information at any time and that it can only be shared in a secure manner and never emailed. *
YesNo

Declaration: I know that the support I will be offered is funded by the UK
Shared Prosperity Fund *
YesNo