Registration form

If you have any questions please don’t hesitate to contact us: or
This form must be completed and received by Stroud District Council (Community Health & Wellbeing Team) before a young person can commence full participation in this project.

Stroud District Council (SDC) is working in partnership with:
  • Berkeley Vale Primary Care Network (BV PCN)
  • Severn Health Primary Care Network (BV PCN)
  • Jason Conway: a published author, poet and writer based in Gloucestershire
This course is open to young people (aged 16-25 years old) who are registered at any of the surgeries within the Stroud District.

We recognise the ability of competent young people to also provide consent. As such, this form should be signed by the young person and their parent or legal guardian if under 18.

Data Protection: SDC processes personal data in accordance with the General Data Protection Regulation 2016 and the Data Protection Act 2018. For information about how we process personal data, please refer to the Council’s Privacy Notices which can be found at:

You can withdraw your consent by contacting:

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* 1. Do you understand how to access information about our privacy policy?


We take your privacy seriously and will never sell your information to third parties. 

We are required by law to share information with relevant authorities if we become concerned about someone’s safety.

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* 2. Do you understand how we share your information:


Whilst working with SDC, BV PCN, SH PCN & Jason Conway we may need to contact you with information about the specific project you are involved in. We would like to use your email address in order to get messages to you.

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* 3. Tick here if you are happy to receive information by:


SDC, BV PCN, SH PCN & Jason Conway would like to stay in touch with you. The types of things we might send include: information about opportunities to be involved with our projects and relevant information about partner organisations. You can opt out of receiving information at any time.

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* 4. Tick here if you are happy to receive communications from us by:

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The information below is required to be involved in the project.

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* 6. Please choose the statement that best describes the current situation:

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A parent or guardian of a young person under 18 will need to enter their details below and complete the consent section.


Consent is required before a young person can fully participate in this project run by SDC, SBV PCN, SH PCN & Jason Conway.

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* 8. Young Persons Declaration 

I consent to taking part in this project run by SDC, BV PCN, SH PCN & Jason Conway. I understand that the staff responsible will take all reasonable care of me and other participants.

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* 9. Parental Declaration (for young people under 18)

I confirm that I have parental responsibility for the above young person and consent to them taking part in this project run by SDC, SBV PCN, SH PCN & Jason Conway.

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* 10. Parental consent for online platforms

The named young person can access and use video platforms (e.g. Zoom) that require specific parental consent at the point of use, for the purposes of their involvement in this project.


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* 11. Have you done any writing in the last 3 months?

For example: diary, journalling, putting thoughts on paper, poetry, flash fiction

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* 12. How often do you read?

For example: books, newspapers, magazines, websites, blogs