Join your local Contact the Elderly group for Sunday afternoon tea parties

Title*

e.g. Mr, Mrs, Miss

Name*

First nameLast name

Address*

Address Line 1Address Line 2City / TownCountyPost Code

Telephone number*

Mobile phone number

Date of birth

Email address

Home information

Do you live alone

Yes
No

What floor do you live on

Lift

Yes
No

Is there lift access to your living area?

Family Information

What family do you have?

Where does your family live?

How often does your family visit?

Can you get out by yourself?

Yes
No

Can you use public transport?

Yes
No

Can you get into the back of a 2-door car

Yes
No

Can you get into the back of a 4-door car?

Yes
No

Do you walk with a frame or use a wheelchair?

Yes
No

Do you have problems with your eyesight?

Yes
No

Do you have problems with your hearing

Yes
No

Do you go to any clubs or day centres?

Yes
No

If yes how often?

Doctor Information

Doctors Name

Doctors Phone

Please tell us the name and relationship of your next of kin

Next of kin's name

Relationship of your next of kin

Next of kin's phone number

If there is another person we should contact if we cannot contact you please give us their details

Emergency contact person's name

Emergency contact person's telephone number

Relationship of your emergency contact person

To help us select a driver and the car that would suit you best, please use the space below to tell us anything else you think we need to know. In particular any health matters which you think are advisable for us to be aware of.

Things we should know

It would be a great help to us if you would be kind enough to tell us where you heard about Contact the Elderly.

If you are filling in this form on behalf of someone else, please write your contact details here.

How did you hear about us?

I would like to be offered a place in a "Contact the Elderly" group.

Data Protection Act: I understand and agree that, as part of a Contact the Elderly group, my details will be held in a confidential database which is used only for communications within the Charity

Please check this box to confirm you have read the above*

Confirm data protection*

Fields with an asterisk (*) are required.
If you have any questions, or need help in filling in this form, please feel free to contact us on 0800 716 543.

Be our guest

Join a small local group for monthly Sunday tea, talk and companionship. It is a free service.

Please fill in the application form below if you would like to join your local Contact the Elderly group as a guest.

Home information

Family Information

Doctor Information

Please tell us the name and relationship of your next of kin

If there is another person we should contact if we cannot contact you please give us their details

Become a volunteer

Be our
guest

Support our work

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