Wellbeing and Recovery College Without Walls

Registration Form

Thank you for expressing an interest in attending the Wellbeing and Recovery College. Please complete this Registration Form and send it back to us. Once received, a member of our team will be in contact with you.

Personal Details:

First Name(s)
Surname
Date of Birth
Home Address / Postcode:
Email Address
Telephone Number / Home: / Mobile:
Contact Details in case of Emergency / Name: / Contact telephone number:

Courses for which you want to enrol:

Please complete the table below in order of preference.

Name of Course / Location of Course / Start Date of Course
1.
2.
3.

Additional Support/Assistance:

Is English your first language?YesNo

If you indicated that English is not your first language, do you feel that you might need assistance in understanding the course content?

Yes No

If you have any learning difficulties/disabilities (such as hearing or visual impairment) or medical conditions (such as epilepsy or diabetes), please state them in the box below. This information will only be shared with the trainers, if it is felt necessary to safeguard your wellbeing, and enhance your learning experience within the Wellbeing and Recovery College.

Please indicate in which capacity it is that you are accessing the college.

You can choose more than one option. Please circle your response.

User of Primary Mental Health Service (GP/IAPT/Counselling) / Staff Member
(Please State Employer) / User of Secondary Mental Health Service (CMHT) / Carer/Supporter/Family /Friend / Member of Public

If you are accessing a service which is provided by South Staffordshire and Shropshire NHS Foundation Trust, please provide details of your GP, and the Trust Team/Service that you are working with.

GP Name
Telephone Number for GP Surgery
Care Co-ordinator /Named worker
Name of the Team/Service that you are under
Telephone number of the Team/Service that you are under

Student Declaration:

Please indicate whether you have any unspent ‘relevant’ criminal convictions. Relevant unspent criminal convictions being those against a person (whether violent or sexual), and offences involving drugs or controlled substances.

YesNo

Having an unspent ‘relevant’ criminal conviction does not automatically mean that you will be unable to access a course with the Wellbeing and Recovery College, however the staff team within the college will meet to discuss your application.

Please mark in the box if you would prefer not to be notified by email of spaces available on courses running.

Signed ______Date ______

Please return to by post to:

Beth Moody, Recovery College Coordinator, South Staffordshire and Shropshire Healthcare NHS Foundation Trust, St Georges Hospital, Mellor House, Corporation Street, Stafford ST16 3AG

Equal Opportunities Monitoring:

The Wellbeing and Recovery College collects information from students on key characteristics which can be related to providing equal opportunities for all. The information collected will remain confidential; the data obtained from this section of the registration form will not be linked to the personal details that you have provided above.

Please answer all questions by marking a X.

Gender

Male Female I do not wish to disclose my gender

What is your sexual orientation?

BisexualGay HeterosexualOther Prefer not to say

What is your marital status?

Single Married Civil Partnership Widow/Widower

Prefer not to say

What is your ethnicity?

Ethnic origin categories are not about nationality, place of birth or citizenship. They are the group to which you as an individual perceive yourself to be.

Asian or Asian Background
Bangladeshi
Indian
Pakistani
Any other Asian Background
Black or Black British
African
Caribbean
Any other Black Background / Multi-Cultural
White & Asian
White & Black African
White & Black Caribbean
Any other Mixed Background
White
British
English
Irish
Scottish
Welsh
Any other White Background / Other Ethnic Group
Chinese
Gypsy
Traveller
Eastern European
Any other Ethnic group
Please state:
I do not wish to disclose my ethnic origin.

Nationality, Please Specify ______

Christianity
Atheism
Buddhism
Islam /
Jainism
Sikhism
None
I do not wish to disclose my religion/belief /
Judaism
Hinduism
Other
Please state:

Disability

Do you consider yourself to have a disability? Yes NoPrefer not to say

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