We are excited to announce that the Active Wellbeing team will be offering support in your local area from June 2020.

If you are interested, you can sign up where you will then recieve a response from your Physical Activity Advisor.

If you do complete the sign up form below, please just bear the project start date in mind. Please also be aware that at present, we are offering telephone consultations due to the Covid-19 outbreak. This will continue until the restrictions are lifted by the government.

Active Wellbeing - Eye

Active Wellbeing - Eye

The Babergh and Mid Suffolk project is a three year project between Babergh and Mid Suffolk District Councils and our Active Wellbeing service; a service that supports older adults who are physically inactive to become more active.

Please fill in the details below if you are interested in accessing the service. The Physical Activity Advisor for your area will then be in touch to discuss this further and make you an appointment.

Referral route / how did you hear about us:

Name:

Phone Number:

Date of Birth:

- 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st - January February March April May June July August September October November December - 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921

Email:

How did you hear about the service?

Google search Facebook advert Local magazine Friends/ Family Surgery/ Health Centre/ Health Professional Community Venue Other

I consent for my data and information to be collected and stored for the purpose of being contacted and to process my referral to the Active Wellbeing service. Your data will be stored for the duration of your participation in the service and will be anonymised thereafter. Your data will not be shared with a third party.

Yes

I confirm that I am a patient registered with Eye Health Centre in Suffolk:

Yes No