digital inlusion referral form 2016 - halifax north & east · web viewage uk calderdale...
TRANSCRIPT
DIGITAL REFERRAL FORM
DATE: -------------------------------------------------------------
NAME: -------------------------------------------------------------------------------------------------------
ADDRESS: -------------------------------------------------------------------------------------------------------
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POSTCODE: ---------------------------------------------------------------------
TEL NO: ---------------------------------------------------------------------------
EMAIL ADDRESS: --------------------------------------------------------------
IS THIS A SELF REFERRAL: YES/NO
NAME OF PERSON REFERRING: ----------------------------------------
ORGANISATION and/or
SERVICE:----------------------------------------------------------------------------------------------------------------------
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DO YOU CONSIDER THE CLIENT
TO BE HOUSEBOUND? YES/NO
HAS A PHYSICAL DISABILITY? YES/NO
LIMITED MOBILITY? YES/NO
ABLE TO VISIT A NEARBY LIBRARY FOR VOLUNTEER SUPPORTED IT SESSIONS?
YES/NO
* Please return completed form to Age UK Calderdale & Kirklees, 4-6 Square, Woolshops, Halifax, HX1 1RJ OR Email [email protected].
Name of Volunteer support: …………………………………...…..Date of 1st session: ………………...……………………….....……Description of agreed sessions: ……………………………………………………….......…Age UK Calderdale & KirkleesChoices Centre4-6 SquareWoolshops t 01422 399 830Halifax e [email protected] 1RJ www.ageuk.org.uk/calderdaleandkirklees Age UK Calderdale & Kirklees is a registered charity (1102020) and a company limited by guarantee. Registered in England and Wales number 5013745