<p>Self Care Management Team Walsall Palliative Care Centre Goscote Lane Walsall WS3 1SJ 01922 605490 Participant details for Self Care Management Programme BOOKING FORM</p><p>I would like to attend a course on a (please tick √) Morning (10.00am–12.30pm)  Afternoon (1.30pm-4.00pm)  Evening (6.30pm-9.00pm) </p><p>Is there a particular course date that you would prefer? ………………………………………..</p><p>How did you find out about the course? Please tick √</p><p>Leaflet  Friend/Relative  Support Group  Press  Radio  Pharmacy  </p><p>Health Care Professional  eg Dietician Other: …………………………………….</p><p>Title: Mr  Mrs  Miss  Other:……………………… Surname: Forename: </p><p>Address: </p><p>Post Code: e-mail:</p><p>Telephone (Daytime): Telephone (Evening):</p><p>Date of Birth: Age:</p><p>Are you: Retired  Unemployed  Employed </p><p>If you are employed, what is your job …………………………………………</p><p>GP name:</p><p>Address: </p><p>Page 1 of 3 Emergency Contact Details (to only be used in an emergency during the course)</p><p>Name: Relationship To You:</p><p>Telephone Number: Extension:</p><p>Mobile Phone Number: Other Details:</p><p>Individual Needs</p><p>Do you have a long-term health Yes  No  condition? What type of condition do you have? </p><p>Please advise us if there is anything we need to be aware of about your condition so that we can support you?</p><p>Do you use a wheelchair? Yes  No </p><p>It would be helpful for GPs and other Health Professionals to be kept informed about the individuals who are completing the programme so that they can help us assess how much value it has been. However, we cannot, and will not, inform anyone without the consent of the individual. Would you therefore be happy for us to notify your GP when you have successfully completed this course? This will be for information only but your GP may ask how you found the programme. </p><p>Please tick (√) the appropriate box. Yes  No </p><p>All information is treated as confidential. In accordance with the Data Protection Act 1998 we wish to inform you that your details will be kept as a record and held on a database and will not be released to any other individual without your consent.</p><p>……………………………………………….….. ….……………………………… Signature of participant Date</p><p>Please return this document in its completed form as soon as possible to: The Self Care Management Team, Walsall Healthcare NHS Trust, Walsall Palliative Care Centre, Goscote Lane, Walsall, WS3 1SJ.</p><p>Page 2 of 3 Ethnicity</p><p>To help us ensure we are making the course accessible to the diverse range of communities we provide a service for, please complete the following section:</p><p>White </p><p>British  Irish  Any other White Background  ………………………………………….</p><p>Mixed </p><p>White & Black Caribbean  White & Black African  White and Asian  Any other Mixed Background  ……………………………………</p><p>Asian or Asian British </p><p>Indian  Pakistani  Bangladeshi  Any other Asian Background  …………………………………….</p><p>Black or Black British</p><p>Caribbean  African  Any other Black Background  ……………………………………. </p><p>Chinese or other Ethnic Group </p><p>Chinese  Any other Ethnic Group  ……………………………………..</p><p>I do not wish to disclose this information </p><p>Page 3 of 3</p>