Form for potential prisoners

Form for potential prisoners

The Rebels In Prison Support (RIPS) team has set up this form for activists who may face remand or a prison sentence as a consequence of their protest. By filling in this form, you're not committing to go to prison - you're just making sure that if it happens, even if that's unlikely, we'll be able to reach and support you. Any data that you provide in this form will be accessible to the team members of the core RIPS team. You can ask for it to be deleted by contacting rebelsinprisonsupport@proton.me.
Please provide us with your full name as it appears on your ID.

First NameLast Name
Gender pronoun (he/she/they/don't mind/etc)
Is there another name that you use that would be helpful for RIPS to know?
Private email
example@example.com
Email address that people can send messages to whilst you are in prison (NOTE: This is different to your personal email address. You or your primary point of contact (or 'chosen one') will need to set this up e.g. janetinprison@gmail.com and remember the password. The 'chosen one' or a prisoner buddy will then monitor this account for messages and forward them onto you while you are in prison using emailaprisoner). This email address will be shared for supporters to write to you.
example@example.com
Phone number or Signal ID
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What law firm will you use? Or will you self-represent?
If you have been to prison before, what is your prisoner number?
Do you consent to RIPS and your activist organisation sharing your story, including pictures of you, in their media?

Yes, I consent.No, I don't consent.
If you chose "Yes, I consent" above, please upload a picture of yourself that you're happy for your group's media team and RIPS to use.

Cancelof
What is your story and your motivation? This will be used to convey anything you want to the world. Try to be relatable. (the media team may need to edit responses to keep on message but won't change the spirit of what you write.) A short quote for the media team to use can be written here.
Do you consent to your Prisoner Number being shared?

Public (including social media)RIPS and activist groups onlyPrivate (only kept within RIPS Core team so we can contact you and offer support)
Do you have any mental or physical health problems that may affect your prison stay?
Do you have any medication requirements or conditions that require ad-hoc medical attention? This includes medication for mental conditions.
Who would be your primary point of contact (or 'chosen one') if you went to prison?
How could we contact them? (Ideally both phone number and email)
Would you like RIPS to allocate you a Prison Support Buddy whilst you are in prison ?

YesNo
Do you already have a Prison Support Buddy?

YesNo
What is your selected buddy's name?

First NameLast Name
How could we contact them? (Ideally phone number and email address).
Will you requre financial assistance? The CASP Assistance Fund can offer you extra financial support if you have taken action with JSO or IB and are likely to face prison for it AND are likely to be made homeless or incur debt if you are sentenced to prison.

Will you requre financial assistance? The CASP Assistance Fund can offer you extra financial support if you have taken action with JSO or IB and are likely to face prison for it AND are likely to be made homeless or incur debt if you are sentenced to prison.
If so please email CASPfinance@protonmail.com.
Would you be okay with us setting up a Crowdfunder if your absense? (if you need it)
Payment:

Full Name on CardSode Code and Account Number
This information about financial assistance may be shared with CASP Financial, none of your other details aside from name/contact information will be shared with them and will be in accordance to GDPR guidelines.

Please use this space if there is anything else that you would like RIPS to know or if there is anything specific that you don't want shared?
We will store this data on a Google spreadsheet that can be access by a small group of RIPS volunteers. We will share it with your prisoner buddy, if you have requested one, and the Media & Messaging team, if you consented to them sharing your story. You can request for this data to be deleted anytime by contacting rebelsinprisonsupport@proton.me. Do you consent to these conditions?

Yes, I consent.No, I don't consent.
Should be Empty: