Smile Project Befriending Registration Form

Groundwork want to ensure we deliver products and services which local people can gain the most benefit from, please complete this form to help us process your application for the Smile befriending service. The information you are asked to provide here will help us to understand a little more about your personal circumstances, and how we may be able to support you through our services.

Essential Information About Me:
This information will help us register you with our service, please complete all questions marked with an * other questions are optional, but will help us understand how to support you best. If you are filling out this form on behalf of someone else please make sure you add your contact details at the last section on this form.
Full Name:*
Age at Date of Application:
(This information will be used to help us understand how many people using Smile Befrienders are aged over 55)
Home Address:*
Home Telephone No:*
Mobile Telephone No:*
Email address:
Special Communication Requirements:
(please tell us if you have any communication needs, or preferences you would like our Befrienders to be aware of e.g. you may require letters to be in large print, or may prefer a telephone call instead of a text message)
How did you hear about SMILE:*
Emergency Contact Details:
(Usually Next of Kin, or the person you would like us to inform in an emergency, e.g. if you were taken to hospital)
Name:*
Address:
Telephone Number(s):*
Relationship to you:*
I am filling out this form on behalf of someone else:
If you are filling out this form for someone else, please give us the following information in addition to the details as listed above:
Your Name:
Contact number:
Have you got consent to make this referral:
- Yes
- No
How do you know this person:
How did you hear about SMILE:
Data Protection Statement & Consent*
I agree to the privacy policy.
By ticking the box above, you are agreeing and understand the information you supply will be shared Groundwork Greater Nottingham. Your contact details will not be shared with any other Organisation without your consent or used for any purpose. If you are referring someone to the service you must have their consent to do so. By ticking above, you confirm that the person you are referring has consented to their details being shared

Smile Project Befriending Registration Form

Essential Information About Me:

Emergency Contact Details:

I am filling out this form on behalf of someone else: