DA Reopening April 2021

Dementia Active Restart April 2021
Place preference: you may tick more than one. Please note, it may not be possible to allocate all places chosen, priority will be given to those formerly attending each group. *

St Hugh’s church, restarting on 15th April 2021, 11.30 am - 1.30 pm Aynho Village Hall, restarting on 16th April 2021, 11.30 am - 1.30 pm Bucknell Village Hall, restarting on 20th April 2021, 12.15 pm - 2.15 pm Please tick here if you require transport
Sessions will continue to last for 2 hours until all Covid restrictions have been lifted nationally at which point they will be extended to 3 hours.
Member’s name *

First Name Last Name
Address, if different from that on our records.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Contact's name

First Name Last Name
Contact phone numbers if these have changed from the numbers we currently hold on our records.

Area Code Phone Number
Phone Number

Area Code Phone Number
Email
example@example.com
We will contact you as soon as possible via email/phone once places have been allocated.
Should be Empty:

Dementia Active Restart April 2021