Arts Registration Form

This survey is from rb&hArts, the arts team for Royal Brompton & Harefield NHS Foundation Trust, to register your interest in creative opportunities available to staff and patients.

You can learn more about our programme on our website.

Any data you share will be held solely by rb&hArts and will not be shared with any third parties.

1.Which online programmes/activities would you like to register for?

Live music with comedy violinist Adrian Garratt

Singing for Breathing

Crafts workshops and/or 121s

Gardening workshops

Youth Programme including Vocal Beats (music) and RBH Trailblazers (youth forum) for 13-25-year olds

Other (please tell us)

2.Are you registering interest for yourself or are you registering for someone else?

I am registering for myself

I am registering for a patient

I am registering for a loved one

Other (please specify)

3.Please indicate your age group

Under 18

18-25

26-34

35-44

45-54

55-64

65+

4.Please indicate which best describes your situation

Current inpatient of 3 weeks or longer

Current inpatient of 3 weeks or less

Outpatient considered 'extremely vulnerable' to Covid-19 according to NHS and Government guidelines who has shielded in the past 6 months

Family member of current inpatient

Family member of outpatient

Member of staff at Royal Brompton & Harefield NHS Foundation Trust

Other (please tell us)

5.Do you have any access requirements we should be aware of?

6.Please enter your contact details
(Please note your details will be held solely by rb&hArts for the purpose of administrating patient engagement and safeguarding. They will not be shared with any third parties).

Name

Email Address

Phone Number

7.Would you like to receive our monthly e-newsletter for updates on creative opportunities for staff, patients and their families at Royal Brompton & Harefield NHS Foundation Trust?

Yes

8.Are there any other creative activities, performances, workshops or equipment you'd like to see?

Thank you for registering with rb&hArts

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