Register with Chance to Choose

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Please complete this form to give us the information we need to help keep everyone safe and supported.

Your Details

First Name

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Last Name

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Date of Birth

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Profile Picture (optional)

Phone Number

Email Address

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Address Line 1

Address Line 2 (optional)

City / Town

Post Code

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Gender

What is your ethnic group?

What is your current employment status?

Religion

Support & Medical Information

Disability / Support Needs (optional)

I have a support worker / carer who may attend with me

Medical Needs (optional)

Doctor's Surgery Address (optional)

If you need urgent care while you are with us, this information can help healthcare professionals identify your GP surgery.

Doctor's Surgery City / Town (optional)

Doctor's Surgery Post Code (optional)

Please enter a valid UK postcode.

Doctor's Surgery Phone Number (optional)

Allergies (optional)

Emergency Contact

Emergency Contact Name

Relationship to You

Emergency Contact Number

Alternative Contact Number (optional)

Photography & Media Permission

From time to time, Chance to Choose may take photographs or videos during art sessions, exhibitions and events. These may be used to celebrate the group and promote our activities.

Giving permission is optional and will not affect your ability to attend the group. You can change your mind about future use at any time by contacting Chance to Choose.

If you choose Yes, photographs or videos may be used on:

The Chance to Choose website
Social media, such as Facebook and Instagram
Posters, leaflets and other printed publicity
Press, news or other publicity relating to Chance to Choose

Do you give permission for photographs or videos of you to be used?

Yes, I give permission.

No, I do not give permission.

Please choose Yes or No.

How Did You Find Out About Us?

Anything Else?

Additional Information (optional)

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Explore Chance to Choose

Find out more about the group, our art and how to get involved.

Art Gallery

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