North Glasgow Youth Food Guidelines and Healthy Eating Toolkit
North Glasgow Youth Food Guidelines and Healthy Eating Toolkit
North Glasgow Youth Food Guidelines and Healthy Eating Toolkit
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Monitoring Form<br />
Please can you print your details clearly.<br />
Name _________________________________________________<br />
Flat/House No ____________ Address ___________________________<br />
POSTCODE ____________ Age ______________________________<br />
Email<br />
Male<br />
______________________________________________________<br />
Female<br />
Do you have any of the following conditions?<br />
(please tick relevant box -you may tick more than one)<br />
Sensory impairment<br />
Physical impairment<br />
Learning disability<br />
Mental health condition<br />
No Disability<br />
Any other disability<br />
or impairment<br />
Ethnic Group or Background<br />
(please tick relevant box- you may tick more than one)<br />
White Scottish Indian African<br />
Other White British Pakistani Caribbean<br />
White Irish Bangladeshi Chinese<br />
Other white Other (South Asian) Mixed<br />
Black Scottish & other Black<br />
Not known<br />
Other (Please state below)__________________________________<br />
Data confidentiality <strong>and</strong> security<br />
The information provided by you will be held in a secure environment in accordance<br />
with the Data Protection Act (1998). The information will be only be used to assess the<br />
outcome of this project <strong>and</strong> no details will be passed on to any organisations who are<br />
not involved in the outcomes assessment.<br />
Version 1 10/02/2011
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