Breaking Isolation Workshop Registration Survey

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* 3. Preferred Pronouns

He/him

They/them

She/her

Other (please specify)

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* 4. Address

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* 5. Post code

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* 6. Email address

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* 7. Phone number

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* 8. Date of birth

Date

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* 9. What is your gender identity?

Female

Male

Prefer not to say

Prefer to self-describe:.....

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* 10. What is your ethnicity? (Please select )

Asian or Asian British - Bangladeshi

Asian or Asian British - Chinese

Asian or Asian British - Pakistani

Asian or Asian British - other Asian background

Black or Black British - African

Black or Black British - Caribbean

Black or Black British - other Black background

Mixed - other mixed

Mixed - White and Asian

Mixed - White and Black African

Mixed - White and Black Caribbean

Other Ethnic Group

White- British

White - European

White- Irish

White - other white background

Do not wish to disclose

Other (please specify)

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* 11. Please state how affected you are by M.E. Please see the Functional Ability Scale - https://www.actionforme.org.uk/uploads/pdfs/functional-ability-scale.pdf/ Please note that these workshops are more suitable for young people who are moderate - mildly affected.

Very severely affected

Severely affected

Severe - moderate

Moderately

Moderate - mild

Mildly

Virtually recovered

Fully recovered

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* 12. The workshops will take place on Thursdays, 4 - 5:30pm on the dates below. Please can you confirm that you can attend all the following sessions:
Thursday 29 November
Thursday 3 December
Thursday 10 December

Yes, I can confirm that I can attend all the workshop dates

I cannot commit to all the dates. Please use comment box to write your preferred times/days.

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* 13. Are you able to use Zoom video conferencing for the workshops for 1.5 hours?

Yes

Yes, with breaks

No. Please be aware that these workshops are running online due to government guidance, we can keep your details and let you know if we are able to change to face to face for future workshops.

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* 14. We will be using creative activities during the workshops. Please state your preference of activity and we will be sending you a pack in the post.

Collage

Drawing

Creative writing

Other (please state, and we will see if we can arrange for a suitable alternative)

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* 15. If you are under 16, please provide your parent/carer's contact details. We will need to contact them and get consent for you to attend these workshops.

Name

Relationship to young person

Email Address

Phone Number

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* 16. If you are over 16. Please read through and choose your consent for the following statements -

	Yes	No
I give Action for M.E. consent to process my data and keep my personal details and any notes safely and securely on their database. To learn more about how we collect, store and process your information, please view our privacy policy on our website - https://www.actionforme.org.uk/get-information/about-us/our-privacy-policy/	I give Action for M.E. consent to process my data and keep my personal details and any notes safely and securely on their database. To learn more about how we collect, store and process your information, please view our privacy policy on our website - https://www.actionforme.org.uk/get-information/about-us/our-privacy-policy/ Yes	I give Action for M.E. consent to process my data and keep my personal details and any notes safely and securely on their database. To learn more about how we collect, store and process your information, please view our privacy policy on our website - https://www.actionforme.org.uk/get-information/about-us/our-privacy-policy/ No
I give consent to be contacted about these workshops and other future workshops	I give consent to be contacted about these workshops and other future workshops Yes	I give consent to be contacted about these workshops and other future workshops No
I give consent to be contacted by phone.	I give consent to be contacted by phone. Yes	I give consent to be contacted by phone. No
I give consent to be contacted by email.	I give consent to be contacted by email. Yes	I give consent to be contacted by email. No
I give consent to be contacted by text.	I give consent to be contacted by text. Yes	I give consent to be contacted by text. No
I give consent to be contacted by post.	I give consent to be contacted by post. Yes	I give consent to be contacted by post. No

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* 17. What is your preferred method of contact? (please select all that apply)

Phone

Post

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* 18. Please give any other details about your individual needs in order to be able to attend these workshops or future workshops. We can contact you to discuss your needs before the workshops. If you have any questions about the workshops and your individual needs, please email Carla - childrensservices@actionforme.org.uk

Breaking Isolation Workshop Registration

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* 1. Full Name

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* 2. Preferred Name

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* 3. Preferred Pronouns

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* 4. Address

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* 5. Post code

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* 6. Email address

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* 7. Phone number

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* 8. Date of birth

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* 9. What is your gender identity?

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* 10. What is your ethnicity? (Please select )

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* 11. Please state how affected you are by M.E. Please see the Functional Ability Scale - https://www.actionforme.org.uk/uploads/pdfs/functional-ability-scale.pdf/ Please note that these workshops are more suitable for young people who are moderate - mildly affected.

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* 12. The workshops will take place on Thursdays, 4 - 5:30pm on the dates below. Please can you confirm that you can attend all the following sessions:
Thursday 29 November
Thursday 3 December
Thursday 10 December

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* 13. Are you able to use Zoom video conferencing for the workshops for 1.5 hours?

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* 14. We will be using creative activities during the workshops. Please state your preference of activity and we will be sending you a pack in the post.

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* 15. If you are under 16, please provide your parent/carer's contact details. We will need to contact them and get consent for you to attend these workshops.

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* 16. If you are over 16. Please read through and choose your consent for the following statements -

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* 17. What is your preferred method of contact? (please select all that apply)

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Breaking Isolation Workshop Registration

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* 1. Full Name

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* 2. Preferred Name

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* 3. Preferred Pronouns

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* 4. Address

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* 5. Post code

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* 6. Email address

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* 7. Phone number

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* 8. Date of birth

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* 9. What is your gender identity?

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* 10. What is your ethnicity? (Please select )

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* 11. Please state how affected you are by M.E. Please see the Functional Ability Scale - https://www.actionforme.org.uk/uploads/pdfs/functional-ability-scale.pdf/ Please note that these workshops are more suitable for young people who are moderate - mildly affected.

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* 12. The workshops will take place on Thursdays, 4 - 5:30pm on the dates below. Please can you confirm that you can attend all the following sessions:Thursday 29 NovemberThursday 3 DecemberThursday 10 December

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* 13. Are you able to use Zoom video conferencing for the workshops for 1.5 hours?

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* 14. We will be using creative activities during the workshops. Please state your preference of activity and we will be sending you a pack in the post.

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* 15. If you are under 16, please provide your parent/carer's contact details. We will need to contact them and get consent for you to attend these workshops.

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* 16. If you are over 16. Please read through and choose your consent for the following statements -

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* 17. What is your preferred method of contact? (please select all that apply)

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* 12. The workshops will take place on Thursdays, 4 - 5:30pm on the dates below. Please can you confirm that you can attend all the following sessions:
Thursday 29 November
Thursday 3 December
Thursday 10 December