Please tell us the name and relationship of your Next
of Kin?
If different from your Next of Kin, please tell us the name of
who we can get in touch with, preferably locally,
if we cannot contact you on a particular occasion?
To help us select a driver
and the car that would suit you best, please
use the space below to tell us anything
else you think we need to know - in particular,
any health matters which you think advisable
for us to be aware of?
It would be a great help if you would be kind-enough
to tell us where you heard about Contact the
Elderly?
I would like to be offered a place in a Contact the Elderly Group.
Data Protection Act: I understand
and agree that, as part of a Contact the Elderly
Group, my details will be held in a confdential
database which is used only for communications within
the Charity.
If you have any questions, or need help in filling
in this form, please feel free to contact us
on 0800 716 543
