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Community Cookery School - Self Referral Form
Please choose one or more of the following qualifying criteria
Loneliness and isolation
People with caring responsibilities
Families with young children
Young people aged 14-18 years old
Cost of Living Challenges
Personal Details
First Name
(required)
This field is required
Surname
(required)
This field is required
Date of Birth
(required)
Please select a date
Address Line 1
(required)
This field is required
Address Line 2
Town
(required)
This field is required
County
(required)
This field is required
Postcode
(required)
This field is required
Phone Number
(required)
This field is required
Email Address
(required)
This field is required
Additional Information
Please state which GP Surgery you are registered with?
(required)
This field is required
Are you an unpaid carer?
(required)
Yes
No
How many people live in your household?
(required)
Please select a value
-- Please Select --
Live alone
2 people
3 people
4 people
4+
Are you registered disabled, or do you have any additional needs, please let us know in the box below
Please provide any other relevant information in the box below
Do you or anyone in your household have a food allergy?
(required)
Yes
No
Please specify allergy below
Will the participant be accompanied by an adult for the cooking sessions e.g. parent or support worker?
(required)
Yes
No
By completing and submitting this form, you agree to the processing of your personal information by Westbank Community Health and Care for the purpose of this project
(required)
Yes
No
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