Creative Wellbeing Afternoon with Art4Space
With Gemma and Charlene 15th July 1- 4 pm
Have you attended Artist Agency, free young people workshops at Art4Space or Creative Pathways?
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Yes
No
Are you a young person applying for the course?
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Yes
No
How did you hear about the course?
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Are you a referral organisation applying on behalf of the young person?
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Yes
No
If yes, what organisation and what is your role?
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If no, put N/A
Can you authorise permission to share referral information?
Yes
No
Name of young person
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First Name
Last Name
This section should be completed by or with the young person
Date of birth
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-
Month
-
Day
Year
Date
Postcode
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Phone number
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Email
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example@example.com
Your email will be added to the monthly wellbeing newsletter from Art4Space unless you opt out below.
Opt out
What gender do you identify as?
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Female
Male
Non-binary
Transgender
Intersex
I prefer not to say
Ethnicity
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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
Why are you applying for the course?
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Thanks for applying. We need to take a few answers from you to ensure you fit the funders eligibility, plus support your needs.
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I am a Lambeth resident
I am not a Lambeth resident
I work/volunteer in Lambeth
I study in Lambeth
I used to go to school in Lambeth
I used to live in Lambeth
I have family living in Lambeth
I am 18-30 years old
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Yes
No
I am long term unemployed or low income (receiving benefits) - We will need to see proof of these on your first session.
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Long term unemployed and receving benefits
On low income and receiving benefits
I am long term unemployed
I am on low income
Can you confirm you can attend Wednesday 15th July 1-4 pm?
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Yes
No
Do you have any health conditions (includes mental health) we should know about?
How can we help you get the most out of this course?
Do you give consent for us to share information with other organisations if we think it will benefit you? We will always tell you before we share.
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Yes
No
Do you give us consent to take photos?
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Evidence for your certificate and documentation purposes
For Social Media & marketing purpose
Submit
Should be Empty: