Community Activity/Navigation Sign-up

Likewise Community Activity Sign-up Form

If you need extra support filling in this form, please call 020 7278 4437 or drop by our Community Hub in person Mon-Fri from 9am to 5pm. Please also note - you don't have to fill in this form to attend our 'drop-in' activities. You can see which ones these are on our timetable here: https://www.likewise.org.uk/activity-programme/#whatson. If you'd prefer to drop in first, one of our staff members will go through it with you when you arrive.
About You
Are you filling this form in for yourself, or for someone else?*
YesIf not, briefly tell us why
No, I have not been to Likewise or filled in this form beforeYes, I have been to Likewise, or I have filled in this form before

YesNo
What's your name? *

First NameLast Name
What's your date of birth? (This will help us match your details to the right person, so you can skip some of the questions later on)*

DayMonthYear
Date

Referrer Information

If you are filling this in for someone else, this section is about you and your relationship to the person you are filling in this form for.
Referrer Name*

First NameLast Name
FriendRelativeGPCarerSocial WorkerSupport Worker/Key WorkerOther
Briefly tell us why you are filling in this form on behalf of someone else, and if there is anything you'd like us to know about the person before we contact them*
What practice, service, or organisation are you making this referral from?*
What is your email address?*
example@example.com
What is your number?*
Please enter a valid phone number.Format: 0000-000-0000.

Personal Information

If you are filling this in for someone else, this section is about the person you are filling in this form for.
What's your name?*

First NameLast Name
What's your date of birth? (MM/DD/YYYY)*

DayMonthYear
Date
She/herHe/himThey/themOther
EmailPhoneLetterAny of the above
What's your phone number?
Please enter a valid phone number.Format: 0000-000-0000.
What's your email address?

Confirmation Emailexample@example.com
What's your home address?*

Street Address

Street Address Line 2

CityState

Zip Code
What's your borough of residence?*

Emergency Contact Details

This can be a friend, relative, or someone who supports you. We would only ever contact this person in case of an emergency, and where possible would ask you for your consent first.
Emergency Contact Name*

First NameLast Name
Relationship to Emergency Contact*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (0000) 000-0000.

Demographic Information

All questions in this section are completely optional. We ask them to help us make sure that we are doing our best to make our services available to all.
Ethnicity
Gender Identity
Sexuality
Religion
Do you consider yourself to have a disability? If yes, please tell us more about this below

One last thing...

There's just a few bits to confirm before you send this off to us
YesNoNot right now
Should be Empty:

Likewise Community Activity Sign-up Form