Referral Form September – December 2023 Please enable JavaScript in your browser to complete this form.Participant SectionTo be filled out by workshop attendee. All session start week beginning 4th September.Title *Mr, Mrs, Miss, Ms etc.PronounsHe/HimShe/HerThey/ThemName *FirstLastEmail *Phone *Date of Birth *day/month/yearAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeWhich group would you like to try? *Monday 12pm – 2pm Embroidery (Starts 9th October)Tuesday 12pm – 2pm Drama (Nemo Arts Studio)Tuesday 2:30 – 4:30 Physical Theatre (Nemo Arts Studio)Wednesday 2:30pm-4:30pm Choir (Nemo Arts Studio)Thursday 2:30 – 4:30 Drama (Nemo Arts Studio)Friday 2:30pm – 4:30pm Creative Writing (Nemo Arts Studio)Saturday 12pm – 2pm Visual Art (In person and on Zoom) Nemo Arts StudioSupport NeedsPlease tell us if there is anything you think we should know to help you participate, for example leaving space at the table for wheelchair access, large print or being closer to the tutor to hear better. Referring Agency To be filled out by referrer, if you are self referring please provide emergency contact details.NameFirstLastPhoneEmailRole for instance O.T, CPN, CMHT, Social WorkerDoes the person have a care plan and does this activity contribute towards it?Please describe what outcomes are expected for the participant during their attendance at Nemo ArtsWould you prefer to attend workshops at our studio or online? *OnlineAt our studio (in-person)PhoneSubmit