Join Space2 Join Space2Please complete the form below. Basic InformationTitle Your full name* House number/name and street:* Town* City Postcode* Telephone NumberMobile NumberYour email address* Would you be happy to receive information on Space2 or other Orion activities? Yes No Great. What would be your preferred method for us to get in touch? Telephone Email Text Message Post Your date of birth* 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 Which group are you interested in?-- Please select --ArtwavesBreathe EasyChildren's ChoirClothing RebellionCoffee and ChillFriday Singing CourseGipton GrowersGreen ShootsHeart to ArtMind Body and SoulMindfulness for HealthSeacroft Men's GroupSeasonal Changes WalksSpace2Create- Young People's Art ClubSpace2Sing ChoirTai ChiThriveYoung Peoples Art ClubOtherYou selected 'other' above. Which group interests you that's not on the list? About YouGender Man (including trans man) Women (including trans women) Non-Binary In Another Way Prefer not to say Did not answer Sexual Orientation Heterosexual Gay man Lesbian/Gay woman Bisexual Prefer not to say Other Religion/Belief Buddhist Hindu Muslim Christian Jewish Sikh No Religion No Belief Other Prefer not to say Is your gender identity the same as you were assigned at birth? Yes No Prefer not to say Do you consider yourself to have a disability or long-term health issue? Yes No Prefer not to say If you have answered yes to the above, please provide further information and any medical assistance you may need in the section below:EthnicityWhite White - British White - English White - Irish White - Northern Irish White - Scottish White - Welsh White - Other If other, please describe below Black or Black British Black – African Black - Caribbean Black - British Black – other Please describe below Asian or Asian British Asian – Bangladeshi Asian – Chinese Asian – Indian Asian – Kashmiri Asian – Pakistani Asian – Other Please describe below Other ethnic groups Arab Gypsy or Traveller Roma Any other background Please describe below Mixed/multiple ethnic groups White and Asian White and Black African White and Black Caribbean Any other mixed/multiple ethnic group Please describe below Vulnerable Groups Carer Refugees & asylum seekers Other vulnerable group Prefer not to say Please describe below Using 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 photographs/ film being used in publicity including Twitter, Facebook and Instagram for evaluation on our website I agree to my data being held in print and on database Final Consent Confirmation* I have read and understood the above statement
