Join or Refer a Friend or Neighbour

Member First name *

Member Last name *

Member Address *

Member Date of Birth

Member Telephone Number *

Member Mobile Number

Member Email address

Next of Kin

Next of Kin First name *

Next of Kin Last name *

Next of Kin Telephone Number

Next of Kin Mobile Number

Next of Kin Email Address

Next of Kin Address

Next of Kin Relationship

If referred, please add their details below.

Referred by full name *

Referred by number *

Referred by Email address

Referred by Relationship

GP & Medical

GP surgery & doctor

Medical Conditions

Applicant Detail

Do you live alone?

What family do you have, and how often do you see them?

Are you member of any other clubs?

How often do you get out of the house?

Are you ok to get out and about by yourself?

Do you have any mobility restrictions?

Do you need support getting in and out of a car?

Do you have any dietary requirements or allergies?

Are there any other details our volunteers need to be aware of?

What's the best way to communicate - phone, email, post etc

Consent

Data Protection – Are you happy for the Communi-Tea Circle to hold your details in a confidential, secure database, solely for internal communication and the coordination of member events? *

Event Photo’s – Occasionally we take photos at our events to use on our website, or social media. Are you happy for us to do so? *

Any other comments

Next steps…

One of our coordinators will be in contact to discuss your application and any additional information we may require.

Once we have everything sorted, we can confirm a date for your first event.

Hopefully speak to you soon.

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