Understanding Bereavement 5th May

Interested in attending this workshop?

Please note that there are limited numbers for our courses and we work on a first come first served basis

If you have any issues filling out this form or would prefer to book over the phone contact us on 01226 644900 Mon- Fri 9.00am – 5.00pm

Fields marked (*) are required

Your name (*)

Your email address (*)

Date of birth (*)

Address (*)

Registered GP surgery (*)

Contact telephone number (*)

Can we leave a voicemail on this number if we cannot get in touch directly?(*)
YesNo

Do you have any disabilities or health conditions that may require special consideration when attending a workshop (*)
YesNo
Details:

Are there any adaptations that would help you access the workshop? (*)

YesNo
Details:

How would you describe your ethnicity? (*)
Choose:White BritishPakistaniBlack AfricanWhite IrishBangladeshiBlack CaribbeanAny other White backgroundAny other Asian backgroundAny other Black backgroundWhite & Black CaribbeanIndianChineseWhite & Black AfricanAny other mixed backgroundAny other Ethnic Groupprefer not to sayWhite & Asian