Art for Wellbeing - Basingstoke Discovery Centre - Saturday 9th, 16th, 23rd, 30th November and 7th December 2024

Participants name

Participants date of birth DD/MM/YYYY

Participants title Mr Mrs Miss Ms Other

Participants ethnicity English / Welsh / Scotting/ Northern Irish / British Irish Gypsy or Irish Traveller Any other white background White and Black Caribbean White and Black African White and Asian Any other mixed / multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Prefer not to say

Participants home contact number

Participants mobile number

Have you attended a course in the last 3 years? No Yes

Do you have any additional needs? - mobility or learning support (if yes, please state in the comments box at checkout) No Yes

Eligibility This course will improve my health and wellbeing Do not have a Full Level 2 qualification Have a learning difficulty or disability Receive income support / universal credit Earn less than £18,525 annual gross salary Have school-ages children who qualify for Free School Meals Currently unemployed and seeking work At risk of / have mental health needs At risk of redundancy

Do you have refugee status? No Yes

If the answer is yes, have you been granted leave to remain in the UK under any of the below schemes N/A Afghanistan scheme Hong Kong scheme Ukraine scheme

Are you currently in paid employment? Yes No

If Yes Employed for less than 10 hours per week Employed for 11-20 hours per week Employed for 21-30 hours per week Employed for 31 hours or more per week Self-employed for less than 10 hours per week Self-employed for 11-20 hours per week Self-employed for 21-30 hours per week Self-employed for 31 hours or more per week N/A

Also if Yes, How long have you been in your job (in years and months)

If No I am retired and have been for less than 6 months I am retired and have been for 6-11 months I am retired and have been for 12-23 months I am retired and have been for 24-35 months I am retired and have been for 36 months or more I am looking to get back into employment and have been for less than 6 months I am looking to get back into employment and have been for 6-11 months I am looking to get back into employment and have been for 12-23 months I am looking to get back into employment and have been for 24-35 months I am looking to get back into employment and have been for 36 months or more I am not looking to get back into employment and have been unemployed for less than 6 months I am not looking to get back into employment and have been unemployed for 6-11 months I am not looking to get back into employment and have been unemployed for 12-23 months I am not looking to get back into employment and have been unemployed for 24-35 months I am not looking to get back into employment and have been unemployed for 36 months or more N/A

Are you claiming any of the following types of benefits? None Job Seekers Allowance (JSA) Employment and Support Allowance (ESA) Universal Credit Other State Benefit

Consent for image to be used during the zoom sessions Yes No

How did you hear about the event? Brochure online Leaflet Email Social media Local paper Word of mouth Library website From tutor WI magazine External poster or banner Prefer not to say

Join our mailing list No Yes

I confirm that, by checking out the item, I am providing my signature and confirming that the details I have given are true Yes No