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Mosaic LGBT+ Youth Winter Retreat Registration
Please fill in this form to register your interest in Mosaic LGBT Youth Winter Retreat. Please respond fully or you will be asked to re-submit your registration.
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* Indicates required question
Do you have a guardian consent if you are under 18?
*
I am 18
I do have a consent
What is the participant's gender pronoun?
*
He / Him / His
She / Her / Hers
They / Them / Theirs
Other:
Participant’s legal first name
*
Your answer
Participant’s legal surname
*
Your answer
Participant’s preferred name if other then above
Your answer
Participant’s gender identity
*
Your answer
What is the Particpant’s date of birth?
*
MM
/
DD
/
YYYY
Participants full address including post code
*
Your answer
Particpant’s phone number:
Your answer
Participant’s email address:
Your answer
What is Participant’s t-shirt size?
*
Your answer
What religious/spiritual practices do we need to accommodate for your stay with us and how?
*
Your answer
If you have a disability please tell us about it and advise us on how we can make your Retreat experience accessible.
Your answer
If you have a mental health problem please advise us on what it is and how it demonstrates itself so that we can make sure you are safe and well while in our care:
*
Your answer
If you have dietary requirements please express them below:
Your answer
If you are on any medication please list below including dosage.
Your answer
If you have any allergies please list them below.
Your answer
Are you able to cycle?
*
Choose
Yes I can cycle
No I can't cycle
Are you able to swim?
*
Choose
Yes I can swim
No I can't swim
Emergency contact details name, address and phone number
*
Your answer
Secondary emergency contact details name, address and phone number
*
Your answer
What makes you want to come to the LGBT Youth Winter Retreat?
Your answer
If there is anything else we need to know please provide details here:
Your answer
The cost of the Winter Retreat is £277 per person.
*
I am able to fund it in full in adance
I am able to fund through interest free repayment plan
I am only able to afford part of the cost (please fill in next question)
I am not able to afford it at all (please fill in the next question)
Tell us more about your situation so that we understand your financial circumstances if you are applying for partial or full funding towards the Retreat:
Your answer
By filling in this form I consent to my data being stored and processed to facilitate my access to Mosaic LGBT Youth Winter Retreat.
*
Yes
No
I would like to be added to Mosaic mailing list for news on events and other LGBT programmes that Mosaic LGBT Youth Centre runs
*
Yes
No
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