Arts & Wellbeing Registration Form (2024)
Identity
First Name
Last Name
Pronouns
Please Select
He/Him
She/Her
Them/They
Which name do you like to be known as?
Date Of Birth
Day
1st
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4th
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31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
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1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Do you identify as LGBTQIA+?
Please Select
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 Select
Yes
No
Prefer not to say
Have you been previously engaged with mental health services?
Please Select
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 Select
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 Select
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 Select
Yes
No
Prefer not to say
Programme
Please select your FIRST choice of Raw Sounds project
Please Select
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 Select
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 Select
YES
NO
Was this form completed by a participant or care coordinator?
Please Select
Participant
Care Coordinator
Someone Else
Are you aware of the 15 pound membership fee to take part in Raw Sounds?
Please Select
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
