Breaking Isolation Workshop registration

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Breaking Isolation Workshop registration - January 2023

Thank you for your interest in attending the 'Breaking Isolation' workshops funded by Children In Need.

The workshop is delivered in 3 parts and each session will include time to meet other young people with M.E. whilst doing fun games and creative activities.

The workshop will be on Zoom at 4.15pm - 5.45pm on:

Wednesday 11th January
Wednesday 18th January
Wednesday 25th January

We are targeting this workshop at young people aged between 10-14

Please complete the registration form below. We ask that you agree to attend all 3 sessions (so long as you are well enough on the day of each session), or alternatively you can register your interest for future dates.

Full name *

Preferred name

Preferred pronouns

Address *

Postcode *

Email address *

Phone number *

Date of birth *

YYYY

What is your gender identity

What is your ethnicity?

Please state how affected you are by M.E. Please see the Functional Ability Scale -www.actionforme.org.uk/uploads/pdfs/functional-ability-scale.pdf Please note that these workshops are more suitable for young people who are moderate - mildly affected however, please do contact me to discuss this.

Are you able to use Zoom video conferencing for the workshops for 1.5 hours? *

Yes

Yes, with breaks

No - Please be aware that these workshops are running online due to government guidance, we can keep your details and let you know if we are able to change to face to face for future workshops.

Other:

Do you have access to a camera to use Zoom video conferencing? *

Yes

No, please can you provide me with a camera to use

There is an option for you to do creative activities between sessions as part of the workshops. Please let us know if you would like an activity craft pack? (This will be sent in the post)

Art pack

Creative writing pack

None

Clear selection

What is your preferred method of contact (please select all that apply)

Phone

Post

Please give any other details about your individual needs in order to be able to attend these workshops. We can contact you to discuss your needs before the workshops. If you have any questions about the workshops and your individual needs, please email Keely at 18andunder@actionforme.org.uk

As you are under 16 - we need parental consent for you to attend these workshops. Please can your parent/guardian fill out the following section of this form.

Please read these following statements and confirm your consent for your child/young person.

(You can find further information about how we process and use your data by reading our Privacy Policy, available on the website or we can send you a hard copy)

I give parental permission for them to attend the workshops

I give consent for Action for M.E. to process my child/young person personal data in order to provide a service.

I give consent for my child/young person to be contacted by post

I give consent for my child/young person to be contacted by email

I give consent for my child/young person to be contacted by telephone

Parent/carer email address

Parent/carer telephone number

Submit

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