Wellbeing Mindfulness Arts & Crafts Workshop Consent Form

Wellbeing Mindfulness Arts & Crafts Workshop Consent Form
Participant Information:
Name*

First NameLast Name
Mobile Phone Number*
Please enter a valid phone number.
Borough residing in:Type here*
Workshop Information:
1. Are you able to get up a flight of stairs? (we are situated on the first floor)*

YesNoWill need some support
2. Will you be bringing a carer or Personal Assistant?*

YesNo
3. Do you have any requirements or additional needs that we should be aware of so we can support you in this workshop?*

YesNo
If yes, please specify:
4. Would you like a snack box?*

YesNo
Do you have any food allergies or intolerances?*

YesNo
If yes, please specify: We will try best to accommodate this.
5. Do you consent for you and your work to be photographed?*

YesNoOnly my work
6. I understand that this is in a block of four sessions and will be able to attend them*

YesNo
Additional Information:
Age group:*

16-2425-3435-4445-5455-6465+Prefer not to say
Ethnicity:*

White BritishIrishGypsy or Irish TravellerAny other White background, please specify:Mixed/Multiple ethnic groupsWhite and AsianWhite and Black CaribbeanWhite and Black AfricanAny other Mixed/Multiple ethnic background, please specify:Asian/Asian BritishIndianPakistaniBangladeshiChineseAny other Asian background, please specify:Black/African/Caribbean/Black BritishAfricanCarribeanAny other Black/African/Caribbean background, please specify:Other ethnic group, please specify:Prefer not to say
Please specify if you are from any other ethnic background:
Where did you hear about us:*
Consent:
I hereby give my consent to participate in the Wellbeing Mindfulness Arts & Crafts Workshop and acknowledge that I understand the information provided above. I understand that I am required to attend all sessions.
Signature: *

Clear
Date*

DayMonthYear
Thank you for your co-operation! We hope that you look forward to our workshop!
Date

DayMonthYear
Date
Should be Empty:

Wellbeing Mindfulness Arts & Crafts Workshop Consent Form

Participant Information:

Workshop Information:

Additional Information:

Consent: