Stepping Stones

Chosen Workshop

Age Connects Torfaen TradesCeramicsHome Made FoodsThe Repair Shop (including upcycling)Cake MakingGrowing and managing your allotmentJewellery Making

General Information

First Name

Surname

Date of Birth

Address

Postcode

Telephone Number

Email

GP Surgery

Next of Kin / Emergency Contact

Address (Next of Kin)

Contact Number (Next of Kin)

Relationship to Next of Kin

Medical Information

Do you have any medical conditions that we should be aware of? (e.g. stroke, heart disease, dementia, mental health issues, diabetes, allergies)

Have you received your COVID Vaccinations?
1st2ndBooster

Equal Opportunities

How would you bests describe your ethnic origin?
BritishWelshScottishIrishAsianOther

What is your marital status?
MarriedSingleDivorcedWidowerSeparatedPrefer not to say

Current employment status:
Employed Full TimeEmployed Part TimeRetiredMade RedundantLong Term UnemployedClaiming Benefits

Consent

To assist with your referral, we require your consent to store information about you, the law (General Data Protection Regulations) states that we must receive your consent to do this. All details will be treated confidentially. The Stepping Stones project is funded through the UK Community Renewal Fund, therefore some evaluation data will be shared with third parties, however it will be anonymised. Please read the following sentence and, if you consent, please check mark the box below:

I give my consent to Age Connects Torfaen to record personal information about myself or person I am representing.