Creative Health
For Lambeth residents, who is LGBTQ+ and smoker who is trying to quit. Form to be completed by the person attending or referrer. Please complete where possible ALL sections of the form. The form is confidential.
Name
*
First Name
Last Name
Email
*
example@example.com
Why are you attending Creative Health?
*
Date of birth
*
-
Month
-
Day
Year
Date
Address
*
Address line 1
Address Line 2
City
Borough
Postcode
Phone number
*
Contact permissions
*
Allow Email
OK to contact by phone
Fine with both contact methods
Do you consider yourself a member of the LGBQT+ Community?
*
Yes
No
Are you trying to quit smoking?
*
Yes
No
Can you confirm you can attend all the sessions Wednesdays 2-5.30pm from 26th Feb until 16th April
*
Yes
No
Emergency contact
*
Name of emergency contact
Relation to you
*
Emergency contact's phone number
Emergency contact's email
Gender
*
Female
Male
Non-binary
Transgender
Intersex
I prefer not to say
Ethnicity
*
Arab
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Other
Asian/Asian British: Pakistani
Black/Black British British: African
Black/Black British British: Caribbean
Black/Black British British: Other
Mixed: Other
Mixed: White and Asian
Mixed: White and Black Caribbean
Other Ethnic Group
White: British
White: Irish
White: Other
Prefer not to say
Referrers 's details (put N/A is not relevant)
*
Referrers's Name
Referrer's job title
*
Referrer's phone
Referrer's email
Any allergies we need to be aware of?
*
Is there anything else which it might be useful for us to know
*
Something that will make it easier for you to access the programme?
How did you hear about Creative Health /Art4Space?
*
Do you give us consent to take photos?
*
Evidence for funding applications
For Social Media & marketing purpose
This is a free programme thanks to our funders, however we still have costs to cover and find. Are you willing to make a small contribution towards materials and refreshments, please do below.
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GBP
Donation
Payment Methods
Debit or Credit Card
Please click one of the PayPal options to complete payment and
submit
the form.
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