Parent / Carer Name:

Postcode:

E-mail*:

Add to e-mail list?*

Phone:

Add to Whatsapp group?*

* You may ask to be removed from the Rose Vouchers Project e-mail list and / or Whatsapp group at any time. 

For each eligible child:

Name

Date of Birth

Evidence seen

If pregnant, what is your baby’s due date?

Ethnicity (please tick)

Asian / Asian British:

Black / Black British:

Mixed:

Other:

Afghani

African

Latin American

Aran

Bangladeshi

Caribbean

White and Asian

Syrian

Chinese

Moroccan

White and Black African

Turkish

Indian

Somalian

White and Black Carribean

White British

Pakistani

Other

Other

White Other

Other

Prefer not to answer

Main Language:

English

Other (please specify):

By joining the Rose Vouchers for Fruit and Veg Project you are agreeing to:

·     Collect your vouchers at least every 4 weeks*.

·     Register with Southwark Children and Family Centres or Family Hubs, and their partners.

·     Attend and contribute to sessions and questionnaires to help evaluate the project.

·     Be respectful to everyone involved with the Rose Voucher Project (other participants, volunteers, staff, etc.).

·     Tell us if your circumstances change, such that you are no longer eligible to receive the Rose Vouchers.

Consent:

By completing and signing this form you agree to Southwark Children and Family Centres and their partners sharing the personal information you have provided about yourself and your family with Alexandra Rose Charity for the purpose of monitoring and evaluating the project. This information may be shared with local authorities, funders and any other organisations who register families on to the project and distribute Rose Vouchers. You are also agreeing to use Rose Vouchers only in the way that is explained to you. Inappropriate behaviour, either with regards to the Rose Vouchers, or towards our staff and volunteers, may result in us removing you from the Rose Vouchers Project.

* Important: If you do not collect your Rose Vouchers for more than 4 weeks without letting us know, you may be removed from the Rose Vouchers Project.

Please tick this box and sign the form to show you understand this.

Parent / Carer Signature:

Date:

Staff use only

Evidence seen

Address

Yes / No

Postcode: SE1 / SE5 / SE15 / SE16 / SE17

Income

Yes / No

UC / NRPF / Refugee or Asylum Seeker / Other:

Receiving Healthy Start

Yes / Applying / Not eligible or refused

If refused, reason for refusal:

Any other comments / information:

Staff Name:

Date: