Breathe Sing Sign Up

Sign Up Form

Breathe Sing

Thank you for your interest in the Breathe Sing.

If you require any help completing this form or would like to receive it in a different format please contact us by email via natalie@breatheahr.org.

We look forward to welcoming you. Fields marked with * are mandatory.

Please note, Breathe Sing is only open to former and current patients of Guy’s and St Thomas’ NHS Foundation Trust.

 

Personal Details

*First name/s:

*Surname:

* Post Code:

Mobile number:

*Email:

*Have you experienced any of these lung conditions (Asthma, Bronchiectasis, Chronic Obstructive Pulmonary Disease (COPD), ILD/ IPF, Breathlessness following hospital stay).

Please select Yes or No from the dropdown.

*Are you a current or former Guy’s and St Thomas’ patient?

Please select from the dropdown.

*Please provide Emergency contact information (should anything happen to you at Breathe Sing)

Emergency contact Name:
Emergency contact Telephone:
What is their relationship to you?

*How did you first hear about Breathe Sing? (select from dropdown)

If you selected Other, please say where:

 

Important: Data Protection
Your personal data will be stored securely and not shared with any third party. We’ll only use your number & email address to contact you about the singing group. We will never pass your details on. Full details of our privacy policy can be found here.

* I agree to Breathe Arts Health Research contacting me (you can withdraw consent at any time).

Photo consent
In order to share and promote Breathe’s work, occasionally we may photograph or film a Breathe Sing session or performance. If you do not wish to be included in photography or filming, please inform a member of the Breathe team.

I agree to Breathe Arts Health Research taking photographs for use on website, in evaluation reports and social media.

I’d like to receive the Breathe Arts Health Research monthly newsletter. (Please tick to accept.)