CWTCH Cymru Contact Form

1. About You

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Welcome to CWTCH Cymru (Communities Working Together Can Help). Please complete this form so we can get to know you a little better and to help us understand your needs.
 

1. What is your name? *

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2. Please add your contact details: *

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3. Please enter your date of birth: *

   DD/MM/YYYY 
 
 

4. What is your gender? *

 

5. Emergency contact details

 

6. Do you currently have any of the following conditions? (Please tick all that apply)

 

7. Which of these following statements best describes where you are on your journey with arthritis?

 

8. Overall, how would you rate the impact of your arthritis on your day-to-day life?

 

9. What support do you require from Cymru Versus Arthritis?

 

10. How did you first hear about Versus Arthritis / Cymru Versus Arthritis?

 

11. The CWTCH Cymru project is planning to collect and store contact information for all participants taking part in activities on our database. We will share this information with our CWTCH Cymru Volunteers so that, in case of an emergency, they can get in touch with your emergency contact.

Please tell us how you prefer to be contacted: *

 

12. An external partner will be evaluating the project, and while we will not share contact details directly with the external partner, Versus Arthritis can contact beneficiaries for evaluation research purposes on their behalf.

 

13. By filling in your details, we can send you our latest news, updates and ways you can support Versus Arthritis. Don’t miss out on hearing about our latest research, support services and advocacy campaigns, as well as fantastic volunteering, fundraising and event opportunities at Versus Arthritis. Please tell us how you may be contacted. *

 
You can find more details regarding how we look after your personal data by going to www.versusarthritis.org/privacy

All this information will be treated as confidential.

14. Please indicate below who completed this form, e.g. either yourself on your own (self-referral) or someone filling it in on your behalf. *