Course Enrolment Form (Self-Referral)

We are delighted that you are interested in taking part in a creative course. The questions below are designed to ensure that we can make you feel as safe, welcome, and comfortable on the course as possible, to ensure that we can meet your needs and for you to give your consent and permissions as you see fit.

Please read through our Participation Criteria to ensure that our courses are appropriate for your needs.

If you need any support in completing this form or have any questions about the form, the creative course you are interested in or the Well-City Salisbury project generally, please get in touch with our Project Coordinator, Zoe , via email: wellcity.salisbury@wessexarch.co.uk. You can also get in touch on 07707 296883 Monday-Thursday.

How to Complete this Form

Please complete all sections of the form. If you need support in filling in the form our Project Coordinator is happy to help or you can get a friend, family member or someone in a professional support role to assist you.

Once all the sections are filled in, please return it to the Project Coordinator by clicking submit at the bottom of the form/page.

A. Applicant's personal details

First name:

Last name:

Address & Postcode:

Phone Number:

Mobile number:

Email:

Please tell us why you would like to take part in a Well-City Salisbury creative course:

Which course would you like to attend?

Please tell us what support service(s), if any, you currently use (mental health services/social services/supported housing etc.):

Emergency contact name:

Emergency contact phone number:

Is there any additional support you might need to take part digitally?

Do you have any dietary requirements? (gluten-free, caffeine-free, vegan etc.)

B. Applicant's Medical and Health Information

Well-City Salisbury creative courses involve fine motor skills, such as using a pencil, and some may involve physical activity, such as walking. We will always seek to support the individual needs of participants where possible and it would be helpful for us to know the nature of any mental health needs (such as depression, anxiety etc.) and physical health needs (such as diabetes, mobility issues etc.) you may have.

Please describe any additional support you may need to take part in a creative course:

Is there anything else you would like to share with us to enable us to best meet your needs during your time on the course?

If you have previously taken part in a Well-City Salisbury course, please describe any changes to your mental or physical health (either positive or negative) since then:

If yes, please describe:

GP's name and surgery:

GP's phone number:

Please note: Well-City Salisbury staff are not clinically trained and cannot administer any medication. The participant is responsible, at all times, for any medication and ensuring this has been taken as needed.

C. Identified Support Person

Please identify an individual in a professional capacity – mentor, community group leader, support worker etc. (not a family member or friend) – with whom you feel comfortable talking to should you require support. Ensure you let this person know that you have given their name and that they are happy to be named as a support person. If you are struggling to identify someone, please get in touch with the Project Coordinator to discuss options.

First name:

Last name:

Organisation:

Role:

Phone number:

Email:

D. Previous Participation

(Please skip if this is your first application to take part in a Well-City Salisbury course)

When did you last take part in a Well-City Salisbury course?

Which course did you take part in? (which organisation delivered the course, which artist facilitated the sessions, what was the course about – whatever information you can remember)

From your last experience participating in a Well-City Salisbury course, is there anything we could have done to better support you?

E. Applicant's Consent

Well-City Salisbury take our responsibility for looking after your personal information seriously. We follow data protection legislation when asking for or handling your information.

The information requested on this form is to enable us to fulfil the requirements of the project, ensures that we can contact you, take account of your health and safety, record your volunteering/activity and are able to undertake reporting on the project’s effectiveness. Your personal details will:

Be kept secure and only accessed by those involved with the Well-City Salisbury project
Be kept confidential and will not be released to third parties without your consent
Be anonymised when reporting on the project and for analysis to help us improve our service, unless you tell us you are happy for your name to be used
Be kept for the duration of the project (until Dec 2024) at which point they will be deleted

You can find out more information about the individual Project Partners privacy policies and your rights related to GDPR and DPA here:

ArtCare - https://artcaresalisbury.uk/privacy-policy/
The Salisbury Museum - https://salisburymuseum.org.uk/privacy-statement
Wessex Archaeology - https://www.wessexarch.co.uk/our-privacy-policy
Wiltshire Creative - https://www.wiltshirecreative.co.uk/privacy/

On occasion you might be asked to complete a range of evaluation documents and give feedback verbally as part of a group. If we ask you to do this then the following things will happen with your information:

Your name and personal details will not be shared with anyone - only the people who oversee the evaluation will have access to this.
Your feedback (both from evaluation forms and verbal) will be anonymised, unless you give us permission to include your name, so that it can be shared with a wider audience. Your personal details will remain confidential.
We may approach you directly to seek your permission to use your progression through the course as a Case Study. We will ensure that you will retain your privacy and confidentiality.

By signing this application, you are confirming that you understand that your details will be kept on the Well-City Salisbury database and used for evaluation purposes in accordance with the above data protection statements and agree to the following:

I agree to Well-City Salisbury staff contacting my GP, referrer or other health professional to clarify any details on this form, to inform them of my participation on a creative course and in the event of any health, safety and wellbeing issues which may arise during my attendance on a course.
I agree that if there are any changes to my physical or mental health, I will notify the Well-City Salisbury team at the earliest opportunity.

Communication Permission

I give permission for the following to get in touch with me after the completion of my creative course in relation to further activities and events that might be of interest to me (please tick to opt in):

Well-City Salisbury project Well-City Salisbury project

Project Partner delivering my creative course Project Partner delivering my creative course

All 4 Project Partners (ArtCare, The Salisbury Museum, Wessex Archaeology & Wiltshire Creative) All 4 Project Partners (ArtCare, The Salisbury Museum, Wessex Archaeology & Wiltshire Creative)

Photo/Media Permission

I confirm my consent allowing the Well-City Salisbury project and the Project Partners (ArtCare, The Salisbury Museum, Wessex Archaeology and Wiltshire Creative) to take...

Photos Photos

Video Video

Audio Recordings Audio Recordings

...of me in relation to participating in creative courses and to use pictures, video and recordings of my voice for the purposes of promoting the project, reporting to funders, developing project resources (both hardcopy and digital) and celebrating the project through events such as exhibitions.

I agree for the above selected to be used in the following ways (please tick to agree):

As part of project and Project Partner printed publications (e.g. posters, reports, leaflets) As part of project and Project Partner printed publications (e.g. posters, reports, leaflets)

On Project Partner websites On Project Partner websites

On project and Project Partner social media (Twitter, Facebook, Instagram, YouTube etc.) On project and Project Partner social media (Twitter, Facebook, Instagram, YouTube etc.)

In newspapers, magazines and other third-party printed or digital publications (for example, as part of a project funder case study) In newspapers, magazines and other third-party printed or digital publications (for example, as part of a project funder case study)

As part of project evaluation reports delivered by external evaluators As part of project evaluation reports delivered by external evaluators

As part of project exhibitions and other project related events As part of project exhibitions and other project related events

I agree my name can be published together with photos, videos, and audio of me.

First name only First name only

First and last name First and last name

I would rather my name not be used I would rather my name not be used

I agree my name can be published together with written transcription of my verbal feedback.

First name only First name only

First and last name First and last name

I would rather my name not be used I would rather my name not be used

You may withdraw your consent for any permissions at any point by getting in touch via wellcity.salisbury@wessexarch.co.uk during the duration of the project (until Dec 2024) or by contacting the Data Protection Team at Wessex Archaeology (info@wessexarch.co.uk) after the project has finished.