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Southwark Women's Forum Registration

Expression of interest form

Please complete this form to register your interest in joining the SEL Mind Southwark Women's Forum.

All fields with a red * are compulsory and must be completed for the form to be submitted.

Following submittal, one of our team will call you for a brief screening to confirm your eligibility.

We schedule these between 10-11am on Mondays or 12-1pm on Thursdays and you will be able to state your preference on which day to be contacted below.

Please note that due to limited spaces, further to confirmation of your eligibility to join, you may be added to a waiting list until there is availability.

Identity

Forename

Surname

Date of birth (if you would prefer you can give year of birth e.g. 01/01/1982)

Address

Address 1

Address 2

Town

Post Code

What borough do you live in?

Contact

Landline number

Mobile

Emergency contact/Next of kin details

How would you prefer to be contacted?

Telephone Email Text messages Post

Medical contacts

GP details (please give GP surgery name, address and GP name)

Care coordinator/Key worker/Support worker

Language Information

A screening call is required to process your application. Please state your preference in the adjacent field to be contacted between 10-11am on Mondays or 12-1pm on Thursdays. If we are unable to speak to you within a three-week period, your application will be closed, and you will be required to reapply

Consent

Do you give your consent for us to collect, process and store your demographic data?

Date consent completed (this is the date you are completing this form)

Additional Information

Please give details on what you would like support with