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Black African and Caribbean Emotional Support Group Registration
ESG Registration Form
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1.
What is your first and last name?
(Required.)
*
2.
Contact Number
(Required.)
*
3.
Email Address
(Required.)
*
4.
Do you live in the borough of Lewisham?
(Required.)
Yes
No
*
5.
What is the first part of your postcode e.g. SE6
(Required.)
*
6.
What is your Gender
(Required.)
Male
Female
Non - Binary
Transgender
Prefer not to say
Other (please specify)
*
7.
Which Emotional Support Group would you like to join
(Required.)
Neurodiversity Emotional Support Group 27th January 2025
Neurodiversity Emotional Support Group 28th April 2025
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8.
Age Bracket
(Required.)
Under 18
18-24
25-34
35-44
45-54
55-64
65+
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9.
What is your ethnicity?
(Required.)
Black Caribbean
Black African
Other Black Background (Inc Black British)
White and Black Caribbean
White and Black African
Other Mixed Background
Prefer not to say
Other (please specify)
*
10.
Sexual Orientation
(Required.)
Heterosexual
Gay
Bisexual
Lesbian
Asexual
Other
Prefer not to say
*
11.
Faith/Beliefs
(Required.)
Christian
Buddhist
Muslim
Jewish
Spiritualism
No Religion
Other
Prefer not to say
Current Progress,
0 of 34 answered