Memory Cafe Enrolment Form | Bristol Wellbeing College

Bristol Wellbeing College Enrolment Form

Bristol Wellbeing College is a Second Step Service, partnering with Alzheimer’s Society to provide free workshops at the Memory Café.

To evidence attendance to funders, we would like to enrol you. If you prefer not to enrol, you can still attend our Memory Café workshops but we regret you will be unable to attend other free Bristol Wellbeing College workshops.

Your details

First Name

Surname

Date of birth (DD/MM/YYYY) *

Your main contact number *

(please enter telephone number without spaces)

Your email address

Address line 1

Address line 2

Town

Postcode

Are you registered with a GP Surgery?

Yes

No

Which area is your GP surgery (if you have one)? Which area is your GP surgery (if you have one)?

Inner City & East GP Surgeries *

North & West GP Surgeries

South Bristol GP Surgeries

Would you describe yourself as a Carer?

Tell us about any physical or mental health support needs

Are you receiving support from Dementia Wellbeing Service?

Equality and diversity information

Please help us improve equality, diversity and inclusion in our service by completing the following optional questions (you are still enrolled if you choose not to complete this section):

Gender Gender

Ethnicity Ethnicity

Sexuality Sexuality

Religion / Belief Religion / Belief

Do you consider yourself to be disabled? Do you consider yourself to be disabled?

Using your information

At Second Step, protecting your personal information is very important to us and we will ensure your personal data is kept confidential and held securely.

We use a great deal of information in our services. For example, we process information about current and past service users working with us or receiving support or tenants in our accommodation. For each service Privacy Policies will be presented directly to these individuals in an upfront way, to ensure they clearly understand how we will use their information.

To find out how we use, store and protect information obtained for these purposes please read our
protecting your personal information leaflet [opens as a PDF]

Bristol Wellbeing College Enrolment Form

Your details

Equality and diversity information

Using your information

Second Step

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