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WSWS Self-referral form
Current
Self-referral form WSWS
Complete
Your details
First name
Last name
Date of birth (DD/MM/YYYY)
Address
Postcode
Contact number
Email
Are you under 18?
Yes
No
If you are under 18, please tick this box to indicate you have received parent/guardian consent to get in touch with us
Yes
No
Parent/Guardian full name (if applicable)
Parent/guardian contact number (if applicable)
Parent/Guardian contact email (if applicable)
How did you hear about us?
- Select -
GP
Family/friend
Mental health team
School
Media
Montgomeryshire Wildlife Trust
Social media
Word of mouth
Council
Volunteer
Other
How would you like to get involved?
- Select -
Face-to-face sessions for adults
Face-to-face sessions (11 -17 year olds)
There are a number of ways you can get involved with us. Please choose from the list above the option you would be most interested in.
What do you hope to gain from attending these nature for wellbeing sessions?
Is being with a group of eight people okay?
Yes
No
Details of allergies, physical or mental health concerns, learning disabilities or other needs:
Is there anything else you wish to tell us about?
What is your current occupation?
- Select -
Full-time employed
Self-employed
Full-time student (school/FE/HE)
Part-time employed
Full/part-time volunteer
Carer
Part-time student
Apprentice or other vocational training
Unemployed
Retired
Prefer not to say
Other
Unspent criminal convictions in accordance with the Rehabilitation of Offenders Act 1974 (exceptions) order 1975 &/or (NI) 1979
Equal opportunities
Gender
Male
Female
Non-binary
Prefer not to say
Not known
Ethnicity
White British
White Irish
Irish Traveller
Other White background
Mixed - Black Caribbean & White
Mixed - Black African & White
Mixed - Asian & White
Mixed - Asian & White
Asian/Asian British - Indian
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - any other Asian background
Black/Black British - African
Black/Black British - Caribbean
Black/Black British - any other Black background
Other - Arab
Other - Cornish
Other - Any other ethnic group
Other - prefer not to say
Other - not known
Disability and impairment (Do you identify yourself as a deaf or disabled person?)
Yes
No
Prefer not to say
Not known
Sexuality
Bisexual
Gay man
Gay women/lesbian
Heterosexual/straight
Prefer not to say
Not known
Other
Data Protection
By signing up to our mailing list you are opting in to receive emails about Wild Skills Wild Spaces events, and our further work. We respect your privacy and will never share or sell your details, and you may change your preferences at any time.
Please be aware that this information will be stored securely and retained at least until 31 December 2026, in compliance with the Data Protection Act 2018. For further information please
click here to view our privacy statement
call or email us on 01938 555654 info@montwt.co.uk
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