Sign Up Form – Breathe Sing for Lung Health

*First name/s: *Surname: *Mobile number: *Email: *Confirm 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. yes no Please tell us your lung diagnosis? (e.g. COPD, IPF): *Are you a current or former Guy's and St Thomas' patient? Please select from the dropdown. current patient former patient

*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) Poster Leaflet Through a friend GiST Magazine Patient Support Group GP/ Hospital Staff Member/ Consultant Other (please say) If you selected Other, please say where: 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) yes no If you answered yes to the question above, please give detail below:

I agree to Breathe Arts Health Research occasionally taking screenshots or short recordings of online sessions for promotional and reporting issues. (No personal details will be visible).

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