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Healthier Futures
Healthier Futures self-referral

Healthier Futures self-referral

Self-refer your child/family:

Please complete the following information to enable us to register you for our Healthier Futures programme. Once you have submitted this information a member of our team will contact you to confirm your place.

Which school are you from?(Required)

Fairlands Primary School

Camps Hill Primary School

Ordsall Primary School

Children in year 6 are eligible for this programme which will take place during school hours. Please submit parent/carer details; we are collecting this information to enable us to evaluate how well our programme meets your needs.

A child and their parents/carers are eligible for this programme if they are in school years 4-6 from Sep 2021 I.e. children currently in year 3 will be eligible. Siblings also in these year groups are also eligible.

Number of parents/carers(Required)

1

2

Number of children(Required)

1

2

3

Parent/Carer details

Parent/carer 1

Name of parent/carer 1(Required)

First Last

Age(Required)

Ethnicity(Required)

Phone(Required)

Can we leave a voicemail on the number provided?(Required)

Yes

No

Email(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Parent/carer 2

Name of parent 2(Required)

First Last

Age(Required)

Ethnicity(Required)

Phone(Required)

Can we leave a voicemail on the number provided?(Required)

Yes

No

Email(Required)

Address(Required)

Same as previous

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Parent(s)/carer(s) are requested to join the programme with their child(ren). Please indicate which parent/carer will be joining.(Required)

Parent/carer 1

Parent/carer 2

Both (at the same time)

Both (alternating sessions)

Children details

Child 1

Name of child 1(Required)

First Last

DOB(Required)

MM slash DD slash YYYY

Ethnicity(Required)

School Year(Required)

Child 2

Name of child 2(Required)

First Last

DOB(Required)

MM slash DD slash YYYY

Ethnicity(Required)

School Year(Required)

Child 3

Name of child 3(Required)

First Last

DOB(Required)

MM slash DD slash YYYY

Ethnicity(Required)

School Year(Required)

Goals

What would your family like to achieve through this programme? (select as appropriate)

What would your family like to achieve through this programme? (select as appropriate)(Required)

More information and understanding on healthy family food for a healthier lifestyle

More information and understanding on how to move more as a family for a healthier lifestyle

More information and understanding on how to change our habits for a healthier lifestyle

Please use this space to include any other goals for your family:

Please indicate if there is any reason your child should not take part in physical activity:

Consent 1

I give my consent to participate and be part of the evaluation of the Healthier Futures programme.

Consent 2

I give my permission for my child/children to participate and be part of the evaluation of the Healthier Futures programme.

CAPTCHA

Please be aware in order to evaluate this programme, measurements (height, weight, waist) will be taken.

Work with us

The Xyla Group employs over 1000 people and operate from over 25 office locations nationwide.

We are looking for exceptional individuals to join our organisation who want to develop a long-term rewarding career with a forward-thinking employer.

Our services

We offer health and wellbeing services that can be tailored to suit the needs of local communities and workplaces.

Completely flexible in our approach, we have the capability to create a unique product for each of our clients based on their requirements.

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Xyla Health & Wellbeing, 2nd Floor, Fountain House, 4 South Parade, Leeds, LS1 5QX

info@xylahealth.com

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Registered office address: 9 Appold Street, London, EC2A 2AP | Company registration number 3156103 Xyla Health & Wellbeing is a trading name of Pulse Healthcare Limited registered in England and Wales. | © 2021