Arts & Wellbeing Registration Form (2024)
Identity
First Name
Last Name
Pronouns
Please choose a value
He/Him
She/Her
Them/They
Which name do you like to be known as?
Date Of Birth
Do you identify as LGBTQIA+?
Please choose a value
Heterosexual / Straight
Gay Woman / Lesbian
Gay Man
Bisexual
Queer
Transgender Female
Transgender Male
Prefer not to say
Address
Address1
Address2
Borough
Post Code
Mental Health Services
Are you currently engaged with a mental health service?
Please choose a value
Yes
No
Prefer not to say
Have you been previously engaged with mental health services?
Please choose a value
YES
NO
Which borough is/was this service located?
Contact
Email
Mobile
Preferred method of contact
Mobile
Telephone
Email
Emergency Contact
Full Name
Relationship to Participant
Mobile
Email
Content Consent
I give my consent / permission for my artistic content created during Raw Material sessions, to be used if required on Raw Materials social media and website
Please choose a value
Yes
No
Prefer not to say
Demographic
Gender
Please choose a value
Female
Male
Nonbinary
Female Transgender
Male Transgender
Prefer not to say
Cultural background
Please choose a value
White British
Scottish
Irish
White Other Background
Black African
Black Caribbean
Black British
White and Black Caribbean
White and Black African
Mixed Race
Black Other Backrgound
White/Asian
Asian British
Bangladeshi
Indian
Chinese
Asian Other Background
Prefer not to say
Medical/Dietary needs
Do you have any special medical or dietary needs we should know about?
Care Co-ordinator/Key Worker
Care Co-ordinator/Key Worker
Please choose a value
Yes
No
Prefer not to say
First name
Last name
Contact number
Email address
Support
Do you have any additional requirements in order to participate?
Media Consent
I give my consent / permission for photos and videos to be taken during the project, to be used if required on Raw Materials social media and website
Please choose a value
Yes
No
Prefer not to say
Programme
Please select your FIRST choice of Raw Sounds project
Please choose a value
Beat Lab
DJing
Guitar Sessions
Mindful Music
Move Your Music
The Voice
Vibe Alliance (Band Project)
Please select your SECOND choice of Raw Sounds project
Please choose a value
Beat Lab
DJing
Guitar Sessions
Mindful Music
Move Your Music
The Voice
Vibe Alliance (Band Project)
Why you are interested in this project?
I can commit to all sessions throughout the term, and understand that if I do not attend, my position will be offered to another member.
Please choose a value
YES
NO
Was this form completed by a participant or care coordinator?
Please choose a value
Participant
Care Coordinator
Someone Else
Are you aware of the 15 pound membership fee to take part in Raw Sounds?
Please choose a value
Yes, I will pay the 15 membership at my first session (Cash and Card are accepted)
No, I cannot afford the 15 membership fee and I would like to apply for a bursary.
How did you hear about Raw Material?
Submit
