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. 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

Other information

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

NOT REQUIRED FOR MARMALADE COMPANIONS Will not see anyone on Christmas Day, no friends / family to share some of the day with

NOT REQUIRED FOR MARMALADE COMPANIONS For meal events: Able to self mobilise, get in / out of transport to venue and keen to be with others

Which Marmalade Trust services are you interested in? (Please select one that is most suitable for your current situation)

Area

Consent (required for us to process & store data)

Do you give consent for Marmalade Trust to:

Store your data whilst engaged with Marmalade Trust services and 6 years after taking part in a Marmalade Trusts service

Share your contact details with Marmalade Trust volunteer(s) for the volunteer to carry out their duties

Demographics

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

Gender

Ethnicity

Next of kin

Do you have a next of kin?

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

Next of kin phone number

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

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)

I confirm that a NOK or emergency contact has been added

GP

Name of GP surgery

Address of GP surgery

Phone number of GP surgery

Carer contact

Do you have a carer?

Carer name

How often does your carer visit you?

Carer contact information (phone & agency)

Contact and support

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

Health and wellbeing

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

Are you independent with taking medication?

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

Diet (for Christmas event only)

Dietary requirements

Coeliac

Dairy free

Diabetic Type 1

Diabetic Type 2

Gluten free

Halal

Nut allergic

Vegan

Vegetarian

Other

None declared

Dietary 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?

Do you require any of the following when being transported in a vehicle?

5-door

Front seat

Large boot (for walking aid/wheelchair)

High vehicle

Low vehicle

No specific requirements

Any other issues or concerns we should be aware of?

Do you have any pets? Some volunteers may have allergies

Pet details (for example, 1x dog or 2x cats)

We are unable to take forward the referral without your contact details

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

Your details as referrer

Referrer name

Referrer Organisation name

Phone

By clicking "submit referral" you consent that we may store the information you have provided for the purposes explained above. Please see our data protection policy for more information.

You can read our privacy policy here

Refer to Marmalade Trust's Christmas Cheer here! Please check eligibility criteria and include your details, as referrer, at the end of the form