Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

We would like to contact you about our services from time to time. You can opt out whenever you like, and we won't share your contact details with any other organisations. Are you happy for us to contact you:

By post

By email

By mobile

By text message

Receive newsletters?

Other information

Consent (required for us to process & store data)

Do you give consent for Marmalade Trust to:

Store your data whilst volunteering with Marmalade Trust

Store your data 6 years after volunteering with Marmalade Trust (you can request for your data to be removed at any point)

Next of kin

Do you have a next of kin?

If yes, what is your next of kin's name?

Next of kin relationship to you (e.g. mother, brother, uncle, cousin)

Next of kin phone number

How often are you in contact with your next of kin? For example 2x per week

Is your next of kin the person we should contact in an emergency?

Emergency contact (if no next of kin)

Emergency contact name

Emergency contact phone number

Emergency contact relationship (e.g. friend, neighbour, GP)

GP

Name of GP surgery

Carer contact

Do you have a carer?

How often does your carer visit you?

Carer name

Carer contact information (phone & agency)

Contact and support

Do you receive calls or support from other services or agencies (e.g. Age UK, social services)?

If yes, please give details of services or agencies which support you

How many social contacts do you have in a fortnight? This could be seeing family or friends, meeting people for an activity

Demographics

Date of birth (use arrow next to month & year to scroll)

Gender

Ethnicity

Interests and hobbies (for Marmalade Companions)

Interests and hobbies

Church/religion

Cooking/baking

Gardening

History

Knitting

Reading

Sports

Theatre/art/poetry

Travel

TV/music/radio

Walking/exercise

Wildlife/pets

Interests and hobbies (other)

Health and wellbeing

Are there any health or mental health conditions which might affect you in your volunteer role?

Yes

If yes, please share any health or mental health conditions that we should be aware of

Communication

Do you have any difficulty communicating, for example, understanding or being understood?

Notes on communication

Cognition

Do you have any difficulty remembering or concentrating?

Notes on remembering and concentrating

Hearing

Do you have any difficulty hearing even if using a hearing aid?

Notes on hearing

Vision

Do you have difficulty seeing, even if wearing glasses?

Notes on vision

Self-care

Do you have difficulty with self-care, for example, washing all over or dressing?

Notes on self-care

Toileting

Do you require any of the following toileting aids?

Disabled access

Rails

Raised seat

Toileting aid details

Other health

Do you have any mental health issues which might affect you taking part in Marmalade projects?

If yes, please tick any that you would like us to be aware of

Agoraphobia

Anxiety

Bipolar

Depression

Hoarding disorder

Low mood

Panic attacks

Post-traumatic stress disorder

Schizophrenia

Unknown

None declared

Do you have any other physical health problems which might affect you taking part in Marmalade projects?

Notes on health conditions

Allergies

Do you have any allergies?

Allergy notes

Mobility

Do you use a walking aid?

What type of aid(s) do you use?

Arm brace

Crutches

Leg brace

Mobility scooter

Walking stick

Wheelchair

3 wheeled walker

4 wheeled walker

Other

Unknown

Ability to get in/out of a car

Ability to transfer onto/off chair at venue

Are you able to use steps/stairs?

Any other issues or concerns we should be aware of?

Do you meet the following eligibility criteria? (Tick all that apply)

Living in Bristol, South Gloucestershire or North Somerset

Living on your own, in own or rented home, not currently homeless or in temporary accommodation

Feeling lonely all or most of the time

Would like new social contact, connection and activity, and keen to get out

Will not see anyone on Christmas Day, no friends / family to share some of the day with

For Christmas meal events: Able to self mobilise, get in / out of transport to venue and keen to be with others

For Christmas doorstep visit: Able to self mobilise to get to front door, and keen to have some connection on Christmas Day

I confirm that a NOK or emergency contact has been added

I confirm that I have provided my contact details as referrer below.

Details of referral

Your details as referrer

Referrer name

Your role

Phone

Referrer Organisation name

By clicking "save details" you consent that we may store the information you have provided for the purposes explained above. Please see our privacy policy for more information.

You can read our privacy policy here

Marmalade Companions - up to 16 weeks of telephone support to find new social connections