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The Queen's Diamond Jubilee Volunteering Award 2012

Call our freephone

0800 716543

Tea Parties with Friends

How do I join?

If you are interested in joining a group then please fill in the application form below or, if you would like to talk to someone about joining a group, please call 0800 716 543 or look at the Contact page for details of your regional representative.

Download a printable application form and read our leaflet with more information for older people.

Your Details

Title
First name
Last name
Date of Birth (dd/mm/yyyy)
Address
Town
County
Postcode
Home Telephone
Work Telephone
Mobile Telephone
Email address
Please tell us where you heard of Contact the Elderly?
Continue

Home Information

Do you live alone?
Yes
No
Is there lift access to your living area?
Yes
No

Family Information

What family do you have?
Where does your family live?
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?
Continue

Doctor Information

Doctors Name
Doctors Telephone

Your next of kin

Next of kin's name
Relationship of your next of kin
Next of kin's phone number

Emergency contact

Is there another person we should contact if we cannot get in touch with you?

Emergency contact person's name
Emergency contact person's telephone number
Relationship of your emergency contact person
Continue

Additional Information

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 may need to know. In particular any health matters which you think are advisable for us to be aware of.

All Applicants

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 that is only used for communications within the Charity. I confirm that the above information is correct and that I agree to my details being held as set out above. Please tick the box to confirm.

I agree to the terms