Survive and Thrive Course registration

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Hello, and welcome to your course!

We'll be online every Wednesday12.30 pm - 2.30 pm for six weeks from 10th January 2024. I'll send you the Zoom link when you've completed your form. Looking forward to meeting you!

Duncan Millard (Tutor)

Please fill in your details below. Your details are confidential and will not be shared.

Email *

First name *

Second name *

Home address *

e.g. 36 North Street, Leeds

Postcode *

Phone number *

Phone network (if you need data top-up)

Gender *

Female

Male

Non Binary

Transgender

Prefer not to say

Other:

Ethnic origin *

Asian Pakistani

Asian Indian

Asian Bangladeshi

Asian British

Any other Asian background

Chinese

Arab

Black African

Black British

Black Caribbean

Any Other Black/African/Caribbean background

Mixed/ Multiple Ethnic background

White British

White Irish

Any other white background

Gypsy or Irish Traveller

Prefer not to say

Any other ethnic group

Date of Birth *

YYYY

Communication - please tell us about any communication needs you have , e.g. interpreter, signing.

We want to make our sessions as accessible as we can, especially on those days when you're not feeling great. What would help you to feel comfortable when you're with us?

Where did you hear about this course? *

Please give a name, phone number and email address of someone we can contact in case of emergency. *

We'd like to stay in touch! Please say whether it's okay for us to send you info about Humans Being events, courses, and quarterly newsletter. We will never share your details with anyone else. *

Email is fine

Post is fine

Phone is fine

No thanks, please don't contact me

Required

We sometimes take photographs or video of people on courses that we use on social media, our website, printed publications and local / national press. We need your permission before we take or share photos.

Yes, you can take and share my photo

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