FRIEND MEMBERSHIP APPLICATION FORM

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Name

Address

Post Code:

Phone No.:

Date of Birth:

E-mail:

How did you hear about us?

Family or Care Provider Contact Details:

Name:

Address:

Relationship to you:

Phone No.:

E-mail:

Second Contact (In case of emergency)

Name:

Relationship to you:

Phone No.:

E-mail:

Please supply any relevant/significant information which will help us in working with our friend. Any information given will be respected and kept in accordance with GDPR (2018) regulations.

Family members:

Names of carers:

Special friends:

Pets:

Particular Interests:

Particular Dislikes/Fears/Phobias

Work/School/College/Day Centre:

Medication

Seizures (Yes/No):

Mobility (If in wheelchair, details of transfer or lifting procedure):

Diet

Allergies

If Catholic, the following details would be useful.

Parish/Church:

Sacraments Received (Please tick if has received any of the following):

Baptism

Communion

Confirmation

If non-Catholic you can supply details or leave blank:

Other Christian Denomination:

World Religion:

None:

Are you willing to have your photo taken?

May we use your photo occasionally in P.R. materials?