Open Arms, Champions of Health- 2023

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Service registration form

Email *

First and second name: *

What is your ethnicity? *

How old are you?

For how long you have been living in the UK? *

I was born in the UK

over 20 years

Between 15 to 20 years

Between 10 to 15 years

Between 5 to 10 years

Between 2 to 5 years

Between 1 to 2 years

Less than a year

I live .. *

alone

with my husband/partner

with my husband/partner and children

with my children

With my brother/sister (s)

with my parents

With house/flat-mate (s)

Other:

What is your employment status? (Note, unemployed means someone who doesn't have a job and is not looking for one either) *

Employed

Self-employed

Unemployed

Job seeker

Other:

Are you or your husband/partner in receipt of any of the following benefits? (please check as many as apply) *

Job seekers allowance

Universal credit

Income support

Child benefit

Housing benefit

Disability alloance

None

Other:

Required

What is your address? *

What is your phone number? *

How did you hear about the Open Arms service? *

From an organisation that I have involved with

From a friend/family

been directly contacted by Open Arms/ELREC

Other:

What is/are the reasons that you want to join Open Arms group (please choose as many as apply to you) *

I want to become healthier

I fee lonely and I want to socialise with other people

I feel isolated and I like to meet other people

I want to use the classes and events to improve my English

I want to learn new skills

I would like to volunteer and help with the service

I want to become a Health Champion

Other:

Required

What Open Arms activities you are interested to participate in (please choose as many as applies) *

Body Maintenance Exercise (a gentle stretching exercise to maintain muscle tones and joints)

Face yoga and DIY face massage

Arts & crafts

Dance class

Non-formal English workshops

Sewing

Required

The main method of delivery for this service is online. What type of electronic device do you have access to at home? *

laptop

desktop

tablet/Ipad

android/apple mobile phone

all of above

none of above

Required

In order to take part in activities, you need to be a member of a closed group created for the project on WhatsApp. Do you agree with your name and phone number be added to this group (this means the others in the group can see your name and phone number) *

From time to time; we may take photos and screenshots of the project activities and use it for the evaluation and promotion purposes. Do you agree for photos that you are in them to be used and shared for the above mentioned purposes? *

Yes

Yes, but only the photos that I am in but not my face is not recognisable

Do you have any particular need in order to be able to use our service? please explain. *

YYYY

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