Workshop Registration

Name *

First

Last

Email *

Phone *

Gender *

Date of Birth (dd/mm/yyyy) *

e.g. 15/02/2003

Ethnicity *

Select as many as apply

Other - Please define

Emergency Contact *

First

Last

Relationship to you *

Phone *

Are you currently *

Select only one

What programmes are you interested in *

Select as many as you would like to do

Are you interested in anything else?

We have other services available for you, do you want our youth workers to talk to you about any of these?

How did you find out about the programme? *

If 'Other' please describe