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Name *

First Name

Last Name

Date of Birth *

You must be aged 14-21.

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What's the best way to get in touch with you *

Call

Text

Email

How did you find out about Regeneration Brainery?

School or college

Word of mouth

Instagram

Twitter

LinkedIn

TikTok

Google

News

Other

Gender *

Female

Male

Non-binary

Other

Prefer not to say

Which ethnicity best describes you? *

White - British / English / Welsh / Scottish / Northern Irish

White - Irish

White - Gypsy or Irish Traveller

Any other White background

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Asian or Asian British - Chinese

Any other Asian background

Black or Black British - African

Black or Black British - Caribbean

Any other Black / African / Caribbean background

Mixed or Multiple ethnic groups - White and Black African

Mixed or Multiple ethnic groups - White and Black Caribbean

Mixed or Multiple ethnic groups - White and Asian

Any other Mixed or Multiple ethnic background

Arab

Any other ethnic group

Prefer not to say

Have you had free school meals in the last 6 years?

Yes

No

Don't know

Have your parents been to university?

Yes

No

Don't know

Have you had any experience of being in care and/or living apart from your parents?

Yes

No

Don't know

Have you got caring responsibilities?

Yes

No

Don't know

Do you have refugee or asylum seeker status?

Yes

No

Don't know

Do you have any disabilities or additional needs? *

No, I don't have any additional needs

I have a mobility difficulties

I have a visual impairment

I have a hearing impairment

I have mental heath difficulties

I am dyslexic

I am dispraxic

Other