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.

The first workshops were for young people age between 15 - 18 and were held on Zoom on Thursdays, 11th, 18th and 25th March 2021 from 5 - 6.30pm.

The second workshops are for children and young people age between 8 - 14 and will take place on Zoom on Saturdays, 10th, 17th and 24th April 2021 from 1.30 - 3pm.

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. Please can you confirm below the workshops you would like to attend according to your age and that you can attend all the sessions. 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.

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

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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.

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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.

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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.

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

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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 Carla - childrensservices@actionforme.org.uk

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