Join Space2 Join Space2 Please complete the form below. Basic InformationTitleYour full name*House number/name and street:*Town*CityPostcode*Telephone NumberMobile NumberYour email address* Would you be happy to receive information on Space2 or other Orion activities?YesNoGreat. What would be your preferred method for us to get in touch? Telephone Email Text Message Post Your date of birth* Date Format: DD slash MM slash YYYY Your age*Where did you hear about this service?Please provide the name and telephone number of someone who can be contacted in an emergency:*Have you used any services at the following organisations since April 2017? (please tick) Zest Feel Good Factor Shantona Space2 Touchstone About YouGenderMaleFemaleNon-BinaryTransgenderOtherPrefer not to saySexual OrientationHeterosexualGay manLesbian/Gay womanBisexualPrefer not to sayReligion/BeliefBuddhistHinduMuslimChristianJewishSikhNo ReligionNo BeliefOtherPrefer not to sayDo you consider yourself to have a disability or long-term health issue?YesNoPrefer not to sayIf you have answered yes to the above, please provide further information and any medical assistance you may need in the section below:EthnicityWhiteWhiteWhite - BritishWhite - EnglishWhite - IrishWhite - Northern IrishWhite - ScottishWhite - WelshWhite - OtherPlease describe belowBlack or Black BritishBlack – AfricanBlack - CaribbeanBlack - BritishBlack – otherPlease describe belowAsian or Asian BritishAsian – BangladeshiAsian – ChineseAsian – IndianAsian – KashmiriAsian – PakistaniAsian – OtherPlease describe belowOther ethnic groupsArabGypsy or TravellerRomaAny other backgroundPlease describe belowMixed/multiple ethnic groupsWhite and AsianWhite and Black AfricanWhite and Black CaribbeanAny other mixed/multiple ethnic groupPlease describe belowVulnerable GroupsCarerRefugees & asylum seekersOther vulnerable groupPrefer not to sayPlease describe belowUsing and sharing your information Space2 is registered Data Controller with the Information Commissioners Office under the Data Protection Act 1998 (Reg Number: Z8853903). We collect and use information about you in order to provide the services. We may collect information on paper, or online forms, by telephone, email or a member of our staff may collect information from you in person. We will use the information you provide in accordance with the Data Protection Act 1998 and General Data Protection Regulation (GDPR) (EU) 2016/679. Information will be accurate, where necessary kept up to date and will be kept for no longer than necessary, in line with our retention policy. We will not share information about you with third parties unless required by law. We may also wish to use photographs, films or case studies of you in conjunction with the Orion partnership Better Together, Healthy communities, healthy lives publicity and evaluation. Please tick the relevant boxes if you agree to being used for this purpose. Consent Preferences I agree to my photograph/films being used in publicity including twitter, Facebook and Instagram I agree to my photograph/films being used for evaluation I agree to my photograph/films being used on the Space2 website I agree to my data being held in print and on a database I agree to my photograph/films being used in artwork/exhibitions Final Consent Confirmation* I have read and understood the above statement
