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Community Partner
Living well
Ageing Well
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Participant Details
Name
*
First
Last
Age Group
*
50–59
60–69
70+
Gender
*
Male
Female
Prefer not to say
Ethnicity
*
Language Spoken
*
Phone
*
Email
Health & Support Needs
Any mobility issues?
Yes
No
Any support required?
Consent
I agree to
*
participate in EMAGE sessions
I agree to
*
take my photograph
I agree to
*
anonymised data being used for evaluation
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