CitizenSpace Local

CLUBS:

Please tick after each activity you would like to see running from the Forest Row centre

After School Club
Parents & Toddler
Pre-School Playgroups
Retired Person/Senior Citizens
Youth/Information Centre

CLUBS: Please insert the number of people within that age range you would like that activity to cater for (you can include more than one age range).

Under 12

[Optional]

12-17

[Optional]

18-24

[Optional]

25-34

[Optional]

35-44

[Optional]

45-54

[Optional]

55+

[Optional]

Q10

HOBBIES & HOUSECRAFT: Please insert the number of people within that age range you would like that activity to cater for (you can include more than one age range).

Under 12

[Optional]

Q11

12-17

[Optional]

Q12

18-24

[Optional]

Q13

25-34

[Optional]

Q14

35-44

[Optional]

Q15

45-54

[Optional]

Q16

55+

[Optional]

Q17

PAINTING, DESIGN, etc:

Please tick after each activity you would like to see running from the Forest Row centre.

Do-it- yourself (DIY) – club
Interior design
Model Aircraft/Railway Club
Pottery – making/painting
Quizzes
Video Club

Q18

PAINTING, DESIGN, etc: Please insert the number of people within that age range you would like that activity to cater for (you can include more than one age range).

Under 12

[Optional]

Q19

12-17

[Optional]

Q20

18-24

[Optional]

Q21

25-34

[Optional]

Q22

35-44

[Optional]

Q23

45-54

[Optional]

Q24

55+

[Optional]

Q26

SPORTS & PHYSICAL RECREATION: Please insert the number of people within that age range you would like that activity to cater for (you can include more than one age range).

Under 12

[Optional]

Q27

12-17

[Optional]

Q28

18-24

[Optional]

Q29

25-34

[Optional]

Q30

35-44

[Optional]

Q31

45-54

[Optional]

Q32

55+

[Optional]

Q33

PUBLIC AFFAIRS/COMMUNITY SERVICE

Please tick after each activity you would like to see running from the Forest Row centre

Age Concern-carers support service information and advice
Domestic violence drop in centre
Drug awareness
Healthy awareness/information centre, healthy eating, Asthma, baby welfare, Diabetes, therapies
Neighbourhood watch scheme
Police drop in/information centre
Savings group-credit union
Community Fundays
Employment/Job Advice

Q34

PUBLIC AFFAIRS/COMMUNITY SERVICE: Please insert the number of people within that age range you would like that activity to cater for (you can include more than one age range).

Under 12

[Optional]

Q35

12-17

[Optional]

Q36

18-24

[Optional]

Q37

25-34

[Optional]

Q38

35-44

[Optional]

Q39

45-54

[Optional]

Q40

55+

[Optional]

Q41

Please add any other activities that you would like to see being run from the centre and please remember to state the age range

Q42

The Forest Row committee cannot guarantee that all activities that you have chosen will be delivered from the centre if there is a low response to certain activities. However, the Forest Row committee will endeavour to deliver as many activities that the local community have highlighted. If you would like to be kept informed of all activities that will be running from the new Forest Row centre please complete your details below.

Name

[Optional]

Q43

Address

[Optional]

Q44

Postcode

[Optional]

Q45

Telephone number

[Optional]

Q46

Email address

[Optional]

Q47

The London Borough of Havering and the Forest Row committee will keep the above information strictly confidential. Your personal information will not be given to any other organisation or statutory body. Your details will only be used to keep you informed of the timetable of activities/services that the Forest Row centre will be able to deliver to local residents. By signing below you confirm that you understand the above statement and you have agreed to supplying your details.

Signed

Q48

Date