ENRICH web registration

Name*

First Name

Last Name

Postcode*

Date treatment ended*

How did you hear about this service?

Would you be able to attend a weekday or weekend ENRICH program?*

Weekday Saturday mornings only Both weekdays and weekends (Saturday mornings only)

What time of day would you be able to attend the ENRICH program?*

Daytime Evening Both daytime or evenings

Are you able to commit to the full 8-week ENRICH program*

Yes No Unsure

If no or unsure, please explain why?

Email*

Phone*

For landlines, please include your area code.

Comments

Privacy*

I have read and understood the Privacy Policy and Collection Statement below.