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Registration Form:
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Email
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Your email
1. Name of applicant
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Your answer
2. Contact number
Your answer
3.Role/ Name of Organisation
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Your answer
4. Organisation postcode
Your answer
5. How did you hear about us? Please be as specific as possible whether it was through a newsletter, forum or someone. (This help informs our partnership work.)
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Your answer
6. Which part of the region does your work cover? (tick all that apply)
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Birmingham and Solihull
Black Country
Coventry and Warwickshire
Derbyshire
Herefordshire and Worcestershire
Leicester, Leicestershire and Rutland
Lincolnshire
Northamptonshire
Nottinghamshire
Shropshire, Telford & Wrekin
Staffordshire and Stoke-on-Trent
Required
7. How would you describe the predominant geographical spread of your work?
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Neighbourhood
Borough
County
ICS Area (Integrated Care System)
Regional
National
Required
8. What communities does your work/organisation support? (tick all that apply)
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Ethnic Minorities
Disabilities cognitive and/or physical
General public
Mental health needs
Homeless
Addiction
Refugees/migrants
Families
People with a long term health condition
Children/Young people
Adults
Older adults
All of the above
Other (please specify below)
Required
If ticked others, please specify:
Your answer
9. What do you predominantly offer? (You will have a chance to select other choices that are applicable for you in the following section)
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Choose
Arts and culture
Natural environment
Physical activity
Heritage activities
Financial wellbeing
Faith-based
Education
Activities for social connectedness (e.g. as a Community venue, health and wellbeing hubs etc.)
Multiple activities with a specific diagnosis (e.g. learning disability, dementia, recovery with lived experiences etc.)
Support as a CVS/infrastructure organisation
Referrals (i.e. Social Prescribing Link worker)
Statutory services (ie local authority, NHS)
Please select all that apply to your work.
Applicable to my work
Arts and culture
Natural environment
Physical activity
Heritage activities
Financial wellbeing
Faith-based
Education
Support as a CVS/infrastructure organisation
Support as a Community venue (ie health and wellbeing hubs etc.)
Referrals (i.e. Social Prescribing Link worker)
Statutory services (ie local authority, NHS)
Applicable to my work
Arts and culture
Natural environment
Physical activity
Heritage activities
Financial wellbeing
Faith-based
Education
Support as a CVS/infrastructure organisation
Support as a Community venue (ie health and wellbeing hubs etc.)
Referrals (i.e. Social Prescribing Link worker)
Statutory services (ie local authority, NHS)
Clear selection
10. What are your top three reasons for being part of Learning Together Programme? (tick three boxes)
*
Creating partnerships
Learning from others and sharing resources
Increasing understanding of social prescribing
Improve understanding of community development
Explore good models of evaluation and monitoring
Understanding co-production
Exploring new models of delivery
Learning about Community Investment for Social Prescribing
Understanding roles within and between NHS, Local authority and community providers
Others (Please specify below)
Required
If ticked others, please specify:
Your answer
11. Is there anything else that would help us understand your role and what you need to engage with the programme? (e.g. accessibility requirements)
Your answer
**Please note that in order to complete your registration, you will need to select your email updates preferences once you've submitted the form.
A copy of your responses will be emailed to the address you provided.
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