Thank you for your interest.

We are currently delivering this programme as part of a research project (SHAPER) across London and as such by completing and submitting this form you are consenting to us sharing your details with the research team.

Please note: you are not eligible to participate in this research study if you are already engaging in or planning to engage in another singing group during the course of the 10-week programme

Completing this form is the first step in expressing your interest to attend a Breathe Melodies for Mums Programme. Once completed, you should expect to hear from one of our team within two working days. They will be able to provide guidance around the next steps in signing up to attend the programme as well as answer any questions you may have.

If you require any help completing this form or would like to receive it in a different format please contact us by email on or telephone 07511 214 069.

We look forward to hearing from you!

Personal Details

All fields are mandatory, please complete the form in full to ensure your registration is processed as quickly as possible.

Mother's Full Name: Confirm Mother's Full Name: Mother's Date of Birth: Baby's Full Name: Baby's Date of Birth (Please note to be eligible for this programme your baby must be aged 9 months or younger at the start of the programme): Baby's Gender: Email: Confirm email: Telephone: House number & Street: City: Postcode: Country:
Emergency Contact Full Name: Emergency Contact Number: Are you already engaging in another mother and baby group singing activity? If you are engaging in other singing activities with your baby you may have to stop them before joining the research study. GP's Name: GP Practice: City: Postcode: Country: GP's Contact Number: Session Preference:(select from dropdown) Recruitment Method: (select from dropdown) Other, Please Specify: If you have selected GP as your recruitment method, please state which GP surgery you were recruited from:

Do you have any access or support needs to ensure you can take part in this activity? (E.g. wheelchair access, captioning for online activity, large print information, sign language interpretation) If you answered yes to the question above, please give detail below:
Please complete this form after you have read the Information Sheet.


In order for us to then contact you if you are potentially eligible for our study, we would like to ask you to read this consent form. Your information may be subject to review by responsible individuals from the research team for screening, monitoring and audit purposes. Confidentiality will be maintained and you will not be identified in any research outputs. Please read the statements below and tick “yes” or “no”.
I consent to the processing of my personal information for the purposes of being contacted for the study. I understand that such information will be handled in accordance with the terms of the General Data Protection Regulation.
I consent to my contact details being retained so that I may be invited to re-screen in the future, should I not be eligible to enrol in the study at this time based on my screening answers.
I consent to my GP being contacted if there are any concerns for my or my baby’s wellbeing.
Please note: We are currently delivering a research study in London. By submitting this form you are consenting to the Breathe Team sharing any information with the research team as well as the agreement outlined in Patient Information Sheet and Consent Form provided by the research team.

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