Wilder Wellbeing

Wellbeing Registration

Please note that your registration form will be reviewed and you will receive an email to confirm whether you have met the criteria to join the programme. If you have any questions before completing the form please message wilderwellbeing@kentwildlife.org.uk
I understand that any information given by me will be treated as confidential and only be used in relation to my participation in the programme and will be held in accordance with the Data Protection Act 2018.

Your details will be used for Kent Wildlife Trust’s purposes only and will not be sold or passed on to any other organisations. We may need to contact you with information related to the programme, contact will only be made for this purpose, and not for wider Trust contact.

I agree to be contacted by Kent Wildlife Trust e.g. to share information about the programme.

I agree to the information I complete on this form being held by Kent Wildlife Trust.

I am aware that I will be asked to give feedback relating to my wellbeing, as part of the referral process.

I understand that I will be asked to adhere to policies and procedures by the group leaders and I agree that I will carry out only the tasks that I consider I am fit to do.

Your details

We will use these details to contact you about your interest in one our our wellbeing programmes
Name*

First NameLast Name
Pronouns
e.g. She/Her/Him/Her/They/Them
Your age *
Please note programmes are only open to those over 18
Ethnicity
Parent/guardians name

First NameLast Name
Phone Number
Please enter a valid phone number.
Babies details*

Name Age
Email*
example@example.com
Phone number*
Address*

Address

Street Address Line 2

Town

Postcode
Do you have any health needs we should be aware of and if so how can we support you? *
for example physical disability, allergies, anxiety, depression, OCD, dementia.
Why would you like to join this programme? Please tick those that are relevant.*

To meet new peopleGain new skillsTo improve or maintain my mental healthTo improve or maintain my physical healthTo help me quit smokingTo help me stay smoke freeOther
If other, please provide more details
How did you hear about the programme?*
We may be able to assist you with accessing the programme, such as reimbursing your travel costs, parking or arranging transportation. Please provide any details about how we could help below. Keep in mind that we cannot guarantee support, we will contact you to discuss this.
A nominal car park fee is required at this nature reserve. As a programme participant, we can cover this expense. To access this support, please provide your car registration numbers below. If you switch vehicles, promptly inform us of the new registration details.

Emergency contact details

In case of an emergency who can we contact
Details of your emergency contact*

Name Relationship to you e.g. partner, friend, parent
Emergency contact number *

Photo Consent
Please note that photos will be taken of the group which may be used for promoting the work of Kent Wildlife Trust, for example website, social media, newsletters etc. The group leader will let you know when a photo is being taken and you will be able to opt out of photos as they are taken*

Yes, I agree that photos of me can be used by Kent Wildlife TrustNo, please do not use photos of me
Subscribe to our Events Newsletter

Optional
Thank you for taking the time to complete this form. Please press the submit button to send your details to us.
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Wellbeing Registration