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Green Therapy Registration Form

We are able to provide our Green Therapy Courses in conjunction with NHS Suffolk and North East Essex Integrated Care Board. We require some information about you in order to register you to our courses. Please complete this application form with all your details. The information you provide will be stored in a secure way according to Data Protection Regulations.

1.First name(Required.)
2.Surname(Required.)
3.Email address(Required.)
4.Mobile phone number (or home number if you do not use a mobile)(Required.)
5.What is your address?(Required.)
6.Emergency contact name and number - please supply the name and mobile phone number of someone we can contact in the event of an emergency.(Required.)
7.Is there anything we need to take into account or to tell a doctor in the event of an emergency (health condition, emergency medication, allergies, etc.)?(Required.)
8.As you will be working outside on our site, is your Tetanus injection up-to-date?(Required.)
9.Are you registered with a GP Practice?(Required.)
10.What are your motivations for attending our Green Therapy Course? How do you hope to benefit?(Required.)
11.How did you hear about our Green Therapy Courses ?(Required.)
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