Breaking Isolation August Workshop Registration 2021

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.

We will be running the next workshop on Zoom on Tuesday 10th, 17th and 24th August 2021. We are targeting this workshop at young people aged between 15 - 18.

Please complete the registration form below. We ask that you agree to attend all 3 sessions, or alternatively you can register your interest for future dates.

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* 1. Full Name

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* 2. Preferred Name

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* 3. Preferred Pronouns

He/him

They/them

She/her

Other (please specify)

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* 4. Address

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* 5. Post code

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* 6. Email address

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* 7. Phone number

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* 8. Date of birth

Date

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* 9. What is your gender identity?

Female

Male

Prefer not to say

Prefer to self-describe:.....

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* 10. What is your ethnicity? (Please select )

Asian or Asian British - Bangladeshi

Asian or Asian British - Chinese

Asian or Asian British - Pakistani

Asian or Asian British - other Asian background

Black or Black British - African

Black or Black British - Caribbean

Black or Black British - other Black background

Mixed - other mixed

Mixed - White and Asian

Mixed - White and Black African

Mixed - White and Black Caribbean

Other Ethnic Group

White- British

White - European

White- Irish

White - other white background

Do not wish to disclose

Other (please specify)

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* 11. Please state how affected you are by M.E. Please see the Functional Ability Scale - https://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.

Very severely affected

Severely affected

Severe - moderate

Moderately

Moderate - mild

Mildly

Virtually recovered

Fully recovered

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* 12. Please can you let us know the times you are able to attend the workshop sessions. We will confirm timing following registrations. We ask if you can commit to attending all sessions as it is one workshop split into 3 parts, however, if you are unwell or unable to attend nearer the time, that is fine.

11am - 12:30pm

2 - 3:30pm

Other

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* 13. 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.

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

Yes

No, but I can borrow one for the workshops

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

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* 15. There is an option for you to do creative activities between sessions as part of the workshops. Would you like an activity craft pack? We will be sending you a pack in the post.

Art pack

Creative writing pack

None

Other (please state, and we will see if we can arrange for a suitable alternative)

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* 16. Would you like to be part of a role play? This would be with another young person to role play a situation with a professional where you are explaining about M.E.

Yes. We may contact you in advance of the workshop if you would like to be involved.

Maybe

No, however, I have ideas for a role play scenario, for example, a situation with a teacher or your GP. Please comment below -

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* 17. If you are under 16, please provide your parent/carer's contact details. We will need to contact them and get consent for you to attend these workshops.

Name

Relationship to young person

Email Address

Phone Number

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* 18. If you are over 16. Please read through and choose your consent for the following statements -

I give Action for M.E. consent to process my data and keep my personal details and any notes safely and securely on their database. To learn more about how we collect, store and process your information, please view our privacy policy on our website - https://www.actionforme.org.uk/get-information/about-us/our-privacy-policy/

I give consent to be contacted about these workshops and other future workshops

I give consent to be contacted by phone.

I give consent to be contacted by email.

I give consent to be contacted by text.

I give consent to be contacted by post.

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* 19. What is your preferred method of contact? (please select all that apply)

Phone

Post

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* 20. Please give any other details about your individual needs in order to be able to attend these workshops or future 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 Jacqueline at 18andunder@actionforme.org.uk