Befriending Network

First Name*

Last Name*

Contact number (mobile or telephone)*

Address line 1*

Address line 2

Address line 3

Town/City*

Postcode*

Age Group (you must be at least 60 years old)

Why would you like to be befriended?

Support Network, ie. Family, friends or neighbours

I consent to my personal information to be kept by The Voluntary Network so that I can receive befriending and other services and information I request to support my independence and wellbeing.
I consent to my personal information being passed to the Volunteer Befriender where appropriate.

I agree to the above

Self Referral for Befriending