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Registration Form
Mandy
2021-11-29T09:54:13+00:00
Register with us
Please use this form to register yourself or on behalf of someone else.
Name
First
Last
Date of Birth (dd/mm/yyyy)
*
Home address
*
Post code
*
Landline number
Mobile number
Email address
Preferred method(s) of contact
*
Email
Telephone
Post
GP name
*
GP telephone number
*
GP address including postcode
*
Are you in receipt of any other mental health services?
*
Mental Health Team
IAPT
Not in receipt of another
Other, please state below
Emergency contact name
*
Emergency telephone number
*
Relationship to you
*
Is this person aware you are sharing their details with us?
*
Yes
No
* If this person is not aware, we will need to contact them to obtain consent to hold their details.
Do you have any additional support needs to enable you to attend a Woking Mind service, e.g. materials in large print? If so, please state below.
NEWS & UPDATES
Woking Mind sometimes sends information about groups, events and other local services via email using Mailchimp. Please indicate below whether you would like to subscribe to any of these email groups. You can change your preferences at any time.
I wish to receive Woking Mind news (including events, fundraising & other local services) by email
*
Yes
No
I wish to receive reminders about groups and activities by email
*
Yes
No
PHOTO CONSENT
Woking Mind would like to use photos showing members and volunteers participating in activities, for information and marketing purposes. This may include, for example, our newsletter, website, leaflets, media releases, social media and other marketing materials. We may like to include a first name with these photos.
Please tick the box below to indicate your preference for inclusion in photos.
*
I give permission for Woking Mind to use my photograph and first name
I give permission for Woking Mind to use my photograph, but NOT MY FIRST NAME
I DO NOT give permission for Woking Mind to use either my photograph or first name
EQUALITY & DIVERSITY MONITORING
Who referred you to our service?
*
Please select
Self referral
GP
IAPT
Housing
Voluntary organisation
CMHRS
Police
Safe Haven
Recovery college
Borough Council
County Council
Other
If other, please state below
How did you hear about our service?
*
Please select
Friend/Family
CMHRS
Internet search
IAPT
Voluntary organisation
Word of mouth
Safe Haven
Police
Recovery College
GP
Borough council
County council
Other
If other, please state below
Ethnicity
*
Please select
English/Welsh/Scottish/Northern Irish/British
Gypsy or Irish Traveller
Irish
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed/Multiple background
Indian
Pakistani
Bangladeshi
Any other Asian background
Arab
Chinese
African
Caribbean
Any other Black/African/Caribbean background
Any other background
Do not wish to disclose
Religion
*
Please select
Christian
Muslim
Hindu
Sikh
Jewish
Buddhist
Other
None
Do not wish to answer
Are you a carer?
*
Yes
No
Do you have a disability?
*
No disability
Physical disability
Learning disability
Autism
Visual impairment
Hearing impairment
Dual sensory loss
Other needs
Do not wish to answer
How do you identify yourself as?
*
Please select
Male
Female
Transgender
In another way
Age band
*
Please select
16-18
19-25
26-40
41-65
65+
Borough of residence
*
Please select
Woking
Mole Valley
Epsom & Ewell
Guildford
Elmbridge
Hampshire
Surrey Heath
Spelthorne
Runnymede
Waverley
Other, please state below
YOUR RIGHT TO CONFIDENTIALITY
We will not normally disclose any information about you to anyone outside of Woking Mind without your knowledge or consent. We may have to, but only in these exceptional circumstances: (1) Where not to do so would break the law (2) Where there is a risk of serious harm to yourself or others. If we disclose information, we will strive to inform you beforehand and will disclose the least information necessary in the circumstances.
DATA PROTECTION
Personal information collected will be dealt with appropriately with the provisions under the General Data Protection Regulations 2018. Anonymised data may be sent to funders or used in marketing materials to inform on Woking Mind activities. We store your data in accordance with the Woking Mind Data Protection and Confidentiality policy. We also file your membership hard copy forms in locked cabinets in our office.
Please confirm that you have completed this form to the best of your knowledge by adding your name and today's date below.
Name
First
Last
Date (dd/mm/yyyy)
*
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