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.

Question Title

* 1. First name

Question Title

* 2. Surname

Question Title

* 3. Email address

Question Title

* 4. Mobile phone number (or home number if you do not use a mobile)

Question Title

* 5. What is your address?

Question Title

* 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.

Question Title

* 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.)?

Question Title

* 8. As you will be working outside on our site, is your Tetanus injection up-to-date?

Question Title

* 9. Are you registered with a GP Practice?

Question Title

* 10. What are your motivations for attending our Green Therapy Course? How do you hope to benefit?

Question Title

* 11. How did you hear about our Green Therapy Courses ?

Page1 / 6
 

T