MembershipPrefixMr.Mrs.Ms.Mx.MissDr.Prof.ForenameSurnameName of membership payee (if different)D.O.BEthnic originStreet AddressCityCountyPostal CodeHome PhoneMobile PhoneEmailLanguages spoke (please state)Country of originReligionEmergency Contact DetailsNameRelationshipPhoneHow do you identify your gender?MaleFemaleNon BinaryTransgenderDo not want to sayOtherGender (if specified other above)Why are you joining Henna?AdviceArts & CraftsFun & Games1 to 1 CounsellingBefriendingWell-Being HubHenna Support GroupMusic & SingingSocial GroupExerciseMonday Club/Chai with HennaESOL/Life in the UKOuting & EventsOtherJoining reason (if other chosen above)What is your status in the UK?Asylum SeekerRefugeeHow long have you been in the country?Are you happy in your current situation?YesNoDo you feel isolated?No AnswerYesNoAny health problems?Do you have any medical history?Do you consider yourself disabled?No AnswerYes (please state)NoDetails of your disabilityMarital StatusSingleMarried/Domestic PartnershipDivorcedWidowedSeparatedDo you receive benefits?NoState PensionPension CreditIncome SupportUniversal CreditJob Seekers AllowanceDisability Living AllowanceAttendance AllowancePersonal Independent PaymentTax CreditsChild BenefitOtherBenefits (Other)Do you live with family?No AnswerYesNoDo you meet your friends?No AnswerYesNoAre you a carer?No AnswerYesNoDo you work?No AnswerYesNoWould you like to volunteer for Henna?No AnswerYesNoWe may use pictures and videos taken during activities and groups on our website and other promotional media. Do you consent to use your image in these materials?YesNoRegister
