Main Referrer/Contact

If other - please state referrer organisation or relationship to participant

Referrer details (i.e. name, job role/relationship, phone number, email address)*

How did you hear about us?*

If other, please state

Surname*

First Name*

Preferred Name

Date of Birth*

Address line 1*

Address line 2

Address line 3

Town*

Postcode*

Landline Telephone No.

Mobile Telephone No.

Primary Email Address

Preferred Method of Communication: Please state either Telephone, Text or Email*

Gender*

If other, self-describe

Preferred Pronouns*

If other, self-description

Participant's emergency contact information: Who can we call in an emergency?

Please provide contact details - including name, relationship and contact phone number*

GP Surgery*

If other - please state details

Do you have a disability / long term health condition?*

Do you have a mental ill-health condition?*

Are you neurodiverse?*

If you have selected yes to any of the above please provide additional details:

Do you have any social and/or communication needs? If so, please provide details

Please provide details of any known risk / safeguarding considerations relating to the participant that St Nicks should be aware of.

If none, please leave blank.

Mental Wellbeing

Physical Wellbeing

Connect with Nature

Learn new skills

Increase social connections

Other

Other reason

Getting active

Gardening

Wildlife conservations

Writing/Poetry

Bushcraft

Getting creative