REMEC Membership Form

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Name* This field is required.
First Name
Last Name
2
Gender * This field is required.
Please Select
Please Select
Male
Female
Non-Binary
Prefer not to say
3
Birth Date
Year
Month
Day
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Email* This field is required.
example@example.com
6
Phone Number* This field is required.
Area Code
Phone Number
7
Next of Kin / Emergency contact
example@example.com
8
Which country represents your ethnic orgin /heritage?Are you a visual learner?
9
Ethnic Background* This field is required.
African
Asian
Arab
Carribean
European
Hispanic or Latino
Mixed Heritage
Native American
Other
10
How would you define your mother tongue and ethnicity?
Huge
Large
Normal
Small
Ok
Ok
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Level of formal of Education* This field is required.
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Which of these REMEC Services might you be interested in?* This field is required.
Food & Nutrition
Internet Cafe & Library
Media & Production
Radio & Music Production
Podcast
Creative Workshops
Creating with Obui
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REMEC Foodbank & Nutrition Programmes
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Would you be interested in our REMEC Food & Nutrition Programme?
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Which Food Supplier would you prefer to receive produce from?* This field is required.
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Do you have any allergies or dietary requirements?* This field is required.
YESNO
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Would you like to receive Subscription Boxes & Food Bank?* This field is required.
Saturday
Sunday
Monday
Dry Snack Box
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Cooked Lunch Box
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General FoodBank
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Dry Snack Box
Cooked Lunch Box
General FoodBank
Saturday
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Sunday
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Monday
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Saturday
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Sunday
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Image Field
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Would you be interested in our REMEC Digital Learning Programmes?
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How competent are you with IT & Digital Skills?* This field is required.
Struggling
I know the Basics
Competent
Expert
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Struggling
I know the Basics
Competent
Expert
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What skills would you like to improve?
Microsoft Office
Emails
Digital & Social Media
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Image Field
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Would you be interested in our REMEC Radio & Music Production Programme?
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What is your level of experience in Music & Radio? * This field is required.
None
Somewhat
Experienced
Recording & Editing
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Producing
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Songwiritng
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Host & Interviewer
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Recording & Editing
Producing
Songwiritng
Host & Interviewer
None
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Somewhat
Row 0, Column 1
Experienced
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None
Row 1, Column 0
Somewhat
Row 1, Column 1
Experienced
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None
Row 2, Column 0
Somewhat
Row 2, Column 1
Experienced
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None
Row 3, Column 0
Somewhat
Row 3, Column 1
Experienced
Row 3, Column 2
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What software are you familiar / comfortable with?
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Large
Normal
Small
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Ok
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Image Field
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Do you use or are you interested in using any of the following?* This field is required.
Canva
Adobe Photoshop
Adobe Premiere / Rush
Adobe Illustrator
Adobe LightRoom
Adobe Indesign
Other
28
Would you like to teach Media Workshops at REMEC ?* This field is required.
YESNO
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Do you have any learning difficulties?* This field is required.cognitive abilities : affecting the way a person learns new things throughout their life
Apraxia of speech: Difficulty speaking, sometimes called verbal apraxia
Central auditory processing disorder (APD): Difficulty understanding and remembering language-related tasks, such as explaining things
Dysgraphia: Difficulty with handwriting, spelling, and organizing ideas
Dyscalculia: Difficulty with math, including understanding arithmetic concepts, doing addition and multiplication
Dyslexia: Difficulty reading words, spelling, understanding sentences, and recognizing words
Dyspraxia (Sensory Integration Disorder) Difficulty with fine motor skills, such as hand-eye coordination, balance
Language processing disorder (LPD): Difficulty processing spoken language, such as attaching meaning to sound groups representing words, sentences
Nonverbal learning disabilities (NVLD): Difficulty understanding facial expressions, body language, tone of voice, and other nonverbal signals
Visual perceptual/visual motor deficit: Difficulty with hand-eye coordination and motor activities
Other
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Do you have any special education needs?* This field is required.require assistance for disabilities that may be medical, mental, or psychological.
Visual or Hearing impairments
Attention deficit hyperactivity disorder (ADHD)
Multi-sensory impairments
Obsessive Compulsive Disorder (OCD)
Physical Disabilities
Medical needs
Other
31
How did you hear about us?
Please Select
Please Select
Friend / Relative
Google
Whatsapp
Instagram
Tiktok
Leaflet
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Do you give consent for images & videos that may include you, to be used for REMEC's web & social media?* This field is required.
YESNO
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Your information will be stored on the REMEC Database and we will contact to you regarding any updates on our services* This field is required.
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Rebuilding REMEC 2025!About Us!
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Are you following us on Facebook?
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REMEC Annual Membership
Access to REM Educational Centre Digital & Physical Learning resourcesPriority BookingsAccess to our Whatsapp CommunityPriority Foodbank & Nutrition servicesMembers-only networking eventsDiscount on REMEC Events & Workshops Discounted REMEC CoursesREMEC Newsletter REMEC Carry Bag ** Administration fee incl
one-time payment.
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