C/O/R/E PROJECT
SELF REFERRAL

Please note – CORE doesn’t currently have childcare facilities, but under 1’s can sometimes accompany their father/carer to some of our sessions. Please ask for more information if this is applicable to you.

First Name *

Last Name *

Email Address

Phone

What is your preferred method of contact?

Postcode

Date of Birth

Age

Why are you interested in the CORE Project? (please tick all that apply)I am experiencing loneliness and/or isolationI'm looking for support with my anxiety / mental health issuesI'm looking for support with my confidence and/or resilienceI've had previous experience of domestic abuseI'm looking for support with my physical wellbeingI'm interested in the crafts and activities availableI'm interested in the courses availableI'm interested in skills and training opportunitiesI'm interested in volunteeringOther (please provide details below)

So we can make reasonable adjustments, do you have any health conditions (medical, mental health, learning or specific physical conditions we need to be aware of? e.g. epilepsy, diabetes, allergies)

If yes, please provide details

Do you have any dependant children?

If yes, how many and how old are they?

Are you a named Carer?

Are you currently working with any other agencies?

If yes, please provide details

Which kind of property are you currently living in? (private rented, housing association, owned etc)

Are you currently working, studying, other?

If working/ studying, what is your work/study pattern? What time of day would you prefer to access the CORE Project?

Do you have any dietary preferences?

Please give any other information you feel the CORE Project would benefit from knowing

Ethnic OriginWhite BritishAsian BritishBlack BritishAsianBlack or African AmericanHispanicArabMultiple Ethnic GroupPrefer not to sayIt would be really useful if you could give us some details on your cultural origin, religion and sexual orientation. All Information is strictly private, anonymous and confidential. This is not compulsory. Thank you for your help.

ReligionNo religionChristianBuddhistHindhuMuslimSikhOtherPrefer not to sayIt would be really useful if you could give us some details on your religion. All Information is strictly private, anonymous and confidential. This is not compulsory. Thank you for your help.

Sexual OrientationAsexualBisexualHeterosexual/straightGayQueerUnsurePrefer not to sayIt would be really useful if you could give us some details on your sexual orientation. All Information is strictly private and confidential. This is not compulsory. Thank you for your help.

GenderMaleIntersexTransPrefer not to say

Would you be interested in receiving a WCT newsletter?

Worcester Community Trust is a registered charity 1112342
Registered Company Number 04722577

Registered Office:
The Green Centre,
Gresham Road, Dines Green,
Worcester, WR2 5QS

Annual Report
Privacy Policy
Safeguarding Everyone Policy

C/O/R/E PROJECTSELF REFERRAL

C/O/R/E PROJECT
SELF REFERRAL