Thank you for your interest in attending the 'Breaking Isolation' workshops. These workshops are funded by Children In Need and will include time to meet other young people with M.E. whilst doing fun games and creative activities.

Please can you complete the registration form below. We ask that you agree to attend all the 3 workshops 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

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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?

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

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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.

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* 12. The workshops will take place on Thursdays, 4 - 5:30pm on the dates below. Please can you confirm that you can attend all the following sessions:
Thursday 29 November
Thursday 3 December
Thursday 10 December

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

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* 14. We will be using creative activities during the workshops. Please state your preference of activity and we will be sending you a pack in the post.

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* 15. 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.

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

  Yes No
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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* 17. What is your preferred method of contact? (please select all that apply)

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* 18. 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 Carla - childrensservices@actionforme.org.uk

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