Wild Pathways
This form is to help us understand some important information about you before you attend sessions with us. We need to understand your needs, and to make sure that we are providing a safe service for all to access.

The information you provide is confidential but some anonymous data may be used for funding purposes.

If necessary we will use your contact details as part of Track and Trace.

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Email *
First Name
Last Name
Age Group
Home Address
Postcode
Phone Number
Ethnicity
Gender
Emergency contact/ carer contact. We may contact this person if we feel there are additional support needs to be discussed, or in case of an emergency.
What is your emergency contact's relationship to you?
Do you have an dietary requirements or food allergies?
Do you have any physical health issues that might affect your ability to participate in activities?
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If yes, please describe them and how we may be able to assist you.
Do you experience any mental health challenges, e.g. anxiety, depression, low mood.
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If yes, please describe them.
Do you consider to have a disability or long term health condition?
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How were you referred onto this project/session? *
If you were referred by another organisation please state *
What are your reasons for attending? What are you hoping to get out of it?
Are you happy for photographs of you to be used for  marketing purposes?
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Thanks for completing the registration form. We are very much looking forward to meeting you.
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