What is it?
What it helps
Free for kids
Free Travel (refund)
Free Course Workbook
Please choose which course you are applying for
September 2017 - Date and venue to be decided
Earning less that £8.45 an hour?
Your contact number
Your GP's name please
Your GP's address please
Are you self referred?
Which organisation has referred you?
Referrer's Contact Number
Require bus fares?
Require a creche?
How many children are aged 0-2 years?
How many children are 2 years old?
How many children are aged over 2 years?
If you have any difficulty doing simple exercise please tell us about it below:
Had any mental ill-health, e.g. anxiety or depression in the last six months? If so tell us here:
Taking any medication at present? If so, let us know what it is and what it is for:
Experienced any recent stressful life-events? If so, briefly tell us here:
Please tell us of anything that would make taking part in the course difficult (i.e. difficulty reading and writing, hearing impairment, childcare, travel, family carer…). We will try our best to help with any difficulty to help you get the most from your course.
you will be invited to contribute to research related to wellbeing;
any data gathered follows the Data Protection Act 1998