Enquiries Capture Form

North Staffordshire Combined NHS Wellbeing and Recovery College Registration Form

Your personal details

Title

First Name

Middle Names

Last Name

Date of Birth

/ /

Address

Town/City

Postcode

Telephone Number

Mobile Number

Personal Email Address

Preferred method of contact

Email
Call to phone
Text/SMS
Post

Emergency Contact We will contact you using your preferred method of contact however if we need to contact you by another method, for example in an emergency, we will use the other contact details you have provided.

Emergency Contact Title

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

About You

Primarily, in what role will you be using the Recovery College? As a:

Name and address of your local doctor or GP practice

Services you access: Please tick the boxes for any statements that apply to you:

Acute inpatient care

How did you hear about us?

Courses

Please select your top three preferred courses (we will endure try to offer you the courses of your choice, however, due to demand this may not be possible).

Once enrolled, you can also email or call us with your chosen courses at Wellbeingcollege@combined.nhs.uk or call on 07971 996653.

Preferred Course 1

Preferred Course 2

Preferred Course 3

We are always expanding our course offer so please let us know if there is an area of interest not currently covered in our timetable

Area of interest not listed

In order for you to join courses we need to be able to send you the links by email or text/SMS.

How would you like to be sent the links for online courses you choose and to receive reminders?

Email
Text/SMS

When we go back face to face, what is your preferred place of learning?

Face to face
online/zoom
Both

Would you like to be added to our email list to receive regular updates and news about courses including our term guide?

Yes No

Your preferred location for attending courses?

Supporting You

Please help us identify your support needs with a brief description of the challenges you have faced or may be addressing through current contact with health services:

Do you have any other additional learning needs?

Your special requirements: Please tell us if you have any special requirements or access needs (e.g. mobility) that we may pass onto trainers before you attend

Would you like additional support in choosing courses?

Yes No

A member of staff will contact you to arrange a meeting.

Are you a member of the UK Armed Forces community?

Equality and Diversity Monitoring

Combined NHS Trust has a legal responsibility to pay due regard to: eliminating discrimination, advancing equality of opportunity and fostering good relations between people of different groups.

To help us to do this it is important we have a good understanding of how the courses run by the Recovery College are being taken up. With up-to-date and accurate information, we are able to:

Better understand our service users & shape the College's services to meet their specific needs

Identify & tackle any issues different people may have when accessing the courses

Ensure that people who need our services the most are able to access them

Your replies will not be used in a way that identifies you however they will help us to understand how community needs may vary; and helps us make informed decisions on how we develop services and target resources.

Gender

Age Group

Marital Status

Sexual Orientation

Faith Affiliation

Other religion or belief system

Ethnic Background: How would you describe yourself?

Confidentiality and our promise to you

Thank you for completing this registration form.

Attendees of all our courses are expected to:

maintain the privacy and confidentiality of other attendees.
not to use mobile phones, computers or recording devises during sessions (unless agreed prior to the day).
inform us as soon as possible if unable to attend.

In return the Recovery College will:

ensure the data you have provided us above is kept within GDPR regulations. Your personal data will not be shared outside of the Recovery College without your consent; with the exception of if we have concerns about your wellbeing. In all cases our primary aim will be to obtain your permission first.
offer courses FREE
involve our services users in the development of our college wherever possible.

By submitting this enrolment form, you are confirming that you have read and understand how your information will be stored / shared by the Recovery College

I agree to the

Yes No