Enquiries Capture Form

Relates to required fields

RCE Wellbeing Hub Registration Form

Personal Details

Title

Other (title)

First Name

Middle Names

Last Name

Date of Birth

/ /

Address

Town/City

Postcode

Telephone Number

Permission to leave an answer message on home number

Yes No

Mobile Number

Permission to leave an answer message on mobile number

Yes No

Personal Email Address

Preferred method of contact

Email
Call to phone
Text/SMS
Post

Emergency Contact Details

We require emergency contact information as we do not have access to any clinical records.

We would only use your emergency contact in an emergency (i.e you were taken to hospital unwell).

Emergency Contact Title

Other (Emergency contact title)

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

Help us know where we need to promote more!

We are eager to know where you found out about us and why you are attending RCE Wellbeing Hub.

By answering these questions you can help us know where we need to promote ourselves to reach a wider range of people.

Primarily, in what role will you be using RCE Wellbeing Hub?

Which of the following applies to you?

Other (Which of the following applies to you)

How did you hear about us?

If 'other', please specify (hear about us)

Courses Available this Term

Please indicate which course(s) you would like to book onto for this term.

The Wellbeing Discovery Programme is a structured 6 week programme (one morning a week) with 1:1 meetings with the Hub staff. If you'd like to register your interest please tick yes and a member of the team will contact you shortly to book your Welcome Meeting

Yes No

Otherwise please choose your chosen courses and start dates from the selection below. You will receive an email confirming your booking within 3 working days.

Preferred Course 1

Preferred Course 1 Start Date

Preferred Course 2

Preferred Course 2 Start Date

Preferred Course 3

Preferred Course 3 Start Date

Preferred Course 4

Preferred Course 4 Start Date

Preferred Course 5

Preferred Course 5 Start Date

Preferred Course 6

Preferred Course 6 Start Date

Other courses of interest, not listed

Supporting Your Learning

We understand that you may have specific conditions (e.g. Dyslexia) that may create additional needs (e.g. coloured overlays).

We encourage you to use the resources/support you already have available, to help you in your learning.

And remember, you're welcome to bring a friend or supporter to help you. They just need to register and enroll on the course you're attending.

To ensure the best learning experience, please answer the following questions as fully as possible.

We have a Peer Support Worker working within the Hub. If you would like an informal 10 minute 'welcome chat' to find out more about the Hub please tick yes

Yes No

Is there anything which makes learning more difficult for you, that you wish the College staff to be made aware of? (e.g. Dyslexia, limited literacy skills, severe mental health challenge)

Yes No

If yes please leave details below

Do you have any physical health conditions (e.g. type 1 Diabetes, Epilepsy) or specific accessibility requirements (e.g. wheel chair user, difficulty with stairs) that may affect your learning or attendance to sessions?

Yes No

If yes please leave details below

Do you have any communication difficulties (e.g. understanding others) that may impact upon your learning?

Yes No

If yes please leave details below

Equality and Diversity Monitoring

Gender

Other (Gender)

What are your preferred pronouns?

Other (preferred pronouns)

Age Group

Marital Status

Sexual Orientation

If 'other' please specify (sexual orientation)

Religion and Beliefs

Other religion or belief system

Disability

Yes No Prefer not to say

Ethnic Background: How would you describe yourself?

Other (ethnic origin)

Student Expectations

Please can you confirm you have read, understood and agree to the following student expectations.

Yes No

You will -

Tell us as early as possible if you're unable to attend a course
Arrive promptly (around 5 minutes before online sessions start) and with an open mind
Take responsibility for your own learning
Use the learning resources made available to you
Update the College of any issues preventing you from getting the most from your courses
Respect our Group Agreement for each session
Treat all students, volunteers and staff with dignity and respect
Not to use any discriminatory or oppressive language or behavi

Consent for sending further information

RCE Wellbeing Hub occasionally receives information from other teams within CPFT, or from our partner organisations, about events or activities that may be of interest or benefit to our students.

Please note: we would not share your contact information with any third party we would simply email or post information to you on their behalf.

We need your specific consent to contact you about these external events and activities.

Please indicate your preference below. (You can change your mind at anytime.)

RCE Wellbeing Hub are becoming more involved in research and development projects. If an opportunity arose for students to become involved in this would you like to be contacted?

Yes No

I am happy to receive updates from RCE Wellbeing Hub about events that may be of interest to me as a student.

Yes No