West London Covid-19 SupportForum for Deaf People

Application Form

West London Covid-19 Support Forum for Deaf People
Applicant Information
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
The session dates are 2nd, 9th, 16th and 23rd February 2021 via Zoom with sessions taking place from 6.30pm - 8pm.
Can you attend all the dates listed above?

Yes No
If no, please state which dates you are able to make?
Why do you want to take part in the group?
Terms and Conditions
Agreement for the Use of Photographic and Audio-visual Material

I give permission for 104 projects CIC and the community fund to take photographs and/or audio-visual footage of myself. I agree that this material may be used for educational purposes by 104 projects CIC and placed online. I also grant to 104 projects CIC, whilst retaining any copyright which I own, the right and licence in any media throughout the world in perpetuity to:

(a) screen any short film (the “Film”), I have been a part of creating, online for educational and health and well-being purposes;

(b) use clips from the Film for promotional purposes;

I have read and understood the conditions of use.
Clear
Gender
Please state your gender

Male Female Other Prefer not to say
Is the gender indicated the same as your gender at birth?
Ethnicity
Please tell us your ethnic origin

Asian/ British - Indian Asian / British - Pakistani Asian/ British - Bangladeshi Asian / British - Chinese Any other Asian Origin Black / British - African Black / British - Caribbean Any other Black Origin White - British (English/Welsh/Scottish or Northern Irish) White - Irish White - Gypsy or Irish Traveller Any other white background Mixed ethnic origin - White and Black Caribbean Mixed ethnic origin - White and Black African Mixed ethnic origin - White and Asian Any other mixed ethnic group
Disability: The Equal Act 2010

The Equality Act 2010 defines disability as a 'physical or mental impairment which has a substantial long term effect on a person's ability to carry out normal day to day activities'
Do you consider yourself to have a disability? 104 projects actively encourage applications from disabled participants, including those with non-visible disabilities and mental health issues.

Yes No Non-visible disability Mental health issues Prefer not to say
Socioeconomic Background
Have you ever been in care? That is, looked after by the state.

Yes, I am currently in care Yes, I was previously in care No, I have not been in care Prefer not to say
Do you or have you received free school meals in the past three years?

Yes No Prefer not to say
Thank you for completing this application form.

Please click submit and we will get back to you shortly
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Application Form

Applicant Information

Terms and Conditions

Gender

Ethnicity

Disability: The Equal Act 2010

Socioeconomic Background