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 will not be eligible for the Breathe Melodies for Mums programme if you take part in another group activity that involves singing during the programme. If you would like to discuss any groups you are currently engaging in, please get in touch with us.

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: Please tick to confirm that you will not be participating in another singing group activity during the 10-week programme
GP's Name: GP Practice: City: Postcode: Country: GP's Contact Number: Session Preference:(select from dropdown) Recruitment Method: (select from dropdown) If you selected Other, please specify: If you selected GP, please state which surgery you were recruited from:
If you selected Poster/Flyer, please state where you saw this:
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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