Enrolment Form (please complete all boxes as not doing so could delay your enrolment) Enrolment Form Full Name* Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AddressEthnic Origin White British White Other Mixed Asian / Asian British Black / African / Caribean Other ethnic group Phone No.Email Do you consent to the recovery college contacting you about future activities?* Yes No We never pass your information to anyone else and you can change your mind at any time, just let us knowGender Male Female Transgender Male Transgender Female Intersex Other e.g. non-binary, gender fluid, etc Prefer not to say Are there any safety or risk issues that we need to know about e.g. have you ever been considered a risk to others?Do you have any specific health or other needs that we need to consider when you become a student?How did you hear about Kind Mind: Recovery Community?Emergency ContactMust be completed. Next of kin, family member, close friend.Full Name* AddressPhoneRelationship to you In the case of an emergency, do we have your consent to contact this person? Yes No Professional SupportMust be completed. Support worker, GP, CPN, etc.Full Name AddressPhoneRelationship to you After discussing with you our concerns and we still feel it is in your best interest, do we have your consent to contact this person? Yes No Disclaimer I consent. I confirm that by applying for a place in the Recovery Community I consider that I am well enough to participate and will take personal responsibility for my well-being. I also confirm that I have read and understood the Code of Conduct and agree to abide by it.