BESTWAY COMMUNITY DEVELOPMENT REGISTRATION FORM

BESTWAY COMMUNITY DEVELOPMENT

REGISTRATION FORM
Bestway community Development needs your permission to record details about you and your enquiry, Please complete the form. Thank you.

Email: admin@bestwaycd.org
Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

POSTCODE
Email*
FAMILY SUPPORT FOR SUBSTANCE*

Personal Support: Private one-on-one sessions to discuss any issues.Referrals: Help connecting with treatment programmes.Workshops: Sessions to learn about substance and prevention.Support Groups: Safe spaces to share experiences with others.Community Resources: Guidance on accessing local services and support.Other
FINANCIAL SUPPORT & WORKSHOP*

Workshop ServicesOne-to-One SupportHelp with BillsAssistance at AppointmentsAny Other Financial Support
DIGITAL INCLUSION*

Workshop (using computers, printers, data SIMs, or any assistance with digital technology)Other
Is there any thing else that you may need Bestwaycd to help you solve?*

NOYES
Number of Adult and Children in the house?
1.Ethnic Origin*

White:BritishIrishWhite & Black CaribbeanWhite & Black AfricanWhite & AsianWhite & OtherAsian or Asian British:IndianPakistaniBangladeshiOtherBlack or Black British:CaribbeanAfricanChinesePrefer not to say
4. Preferred Language:*

EnglishOther - please state:
5. Your Nationality: *
6. Your Occupation*

Employed over 30 hrs• Employed under 30 hrsSelf-employedUnemployed - disabledUnemployed - sicknessUnemployedVolunteerRetiredStudentCarer - elderly/disabledCarer - childrenLooking after home - no dependentsGovt. employment schemePrefer not to say
7. Your Household:*

Single personSingle person with dependant childrenSingle person with non-dependant childrenCoupleCouple & dependant childrenCouple with non-dependant childrenOther - adults onlyOther - with dependant childrenPrefer not to say
8.If you were referred, who ask you to come here? (eg Friend, Organisation)*

Friend Organisation
Consent for the Recording, Storage, and Disclosure of Personal Information

I, the undersigned, hereby grant my consent to Bestway Community Development (Bestwaycd) to record, securely store, and, where necessary, disclose my personal information and details relevant to my enquiry. I acknowledge and understand that, should my case require referral to a partner organisation, my information will be shared with the relevant partner solely to facilitate and support the referral process.
Signature*

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