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Your Administrative Details

These details will not be shared and will only be used by essexlife to contact you.

Your name*: So that we can contact you to review your record details.

Your phone number*: So that we can contact you if we need to.

Your email address*: So that we can contact you if we need to.

Organisation/Activity Details

Title/Name*: The title/name of the organisation or activity. This will be used as your record heading.

Description*: (shift+enter for a new line); A short description of the service or activity.
Please keep it concise and informative. You can put extra information in the 'Any other information' field at the end of the form.

Venue

Address: (shift+enter for a new line); The organisation or activity venue address.

Postcode: The organisation or activity venue postcode.
Please include the full postcode where known.

Website URL: (please include the http:// prefix.); The website address of the organisation or activity if there is one.

Venue notes: (shift+enter for a new line); Any other venue information such as directions or parking etc.

Details

Date(s)/Time(s)/Opening Hours: When can people use the organisation or activity?

Membership is open to: Who is allowed to take part/join?

Age range: (ctrl+click to choose more than one, ctrl+click to remove selection); Is a specific age range covered?

Cost: The cost of the organisation or activity (if there is one).

Booking info: Is there a booking facility? How are bookings taken?

Waiting list: Is there a waiting list?

Disabled facilities: (ctrl+click to choose more than one, ctrl+click to remove selection); If applicable, select the relevant disabled facilities for this organisation or activity.

Any other disabled facilities: Please add any facilities for disabled people which are not listed above.

Referral method: Is a referral needed to use this organisation or activity? If so then how is a person referred?

Child Protection policy: (ctrl+click to choose more than one, ctrl+click to remove selection); If applicable, select the relevant child protection policy for this organisation or activity.

Public Contact Details

Name: (separate individual's names with a semi-colon); The name of the person(s) who can be contacted about this organisation or activity.
You can enter more than one name here.

Address: (shift+enter for a new line); The contact address (which may be different from the venue address).

Postcode: The contact postcode.
Please include the full postcode where known.

Either Telephone*: (separate telephone numbers with a semi-colon); The telephone number(s) at which the organisation or activity contact can be reached.
You can enter more than one telephone number here.

or Email*: (separate addresses with a semi-colon); The email address(s) at which the organisation or activity contact can be reached.
You can enter more than one email address here.

Secondary Telephone: (separate telephone numbers with a semi-colon); The telephone number(s) at which the organisation or activity contact can be reached.
You can enter more than one telephone number here.

Fax: (separate fax numbers with a semi-colon); The fax number(s) at which the organisation or activity contact can be reached.
You can enter more than one fax number here.

Mobile: (separate mobile numbers with a semi-colon); The mobile number(s) at which the organisation or activity contact can be reached.
You can enter more than one fax number here.

Any Other Information

Any other information: (shift+enter for a new line); Any other information which may be relevant to this organisation or activity and which has not already been covered in the description.

Essex County Council will use the information provided on this form only for the purpose you have specified. Information will be treated in accordance with the Data protection Act 1998. See Terms and Conditions