Expression of Interest Form
Thank you for your interest in the AYC Day Club and our Outreach offer. This short form is designed to help us understand who may be interested in the service and how best to contact you. It is not the full registration form and does not guarantee a place in the service. If the service may be suitable or if we require further information, a member of the AYC team will contact you to discuss the next steps. Please only provide brief information at this stage. We will request more detailed information later if you decide to move forward with registration.
Who is completing this form
Name
*
First Name
Last Name
Your relationship to the person who may attend
*
Please Select
Myself
A family member
A friend
An attorney, deputy, or representative
A health or social care professional
Other (please specify)
Please provide further details
Your telephone number
*
Your email address
*
example@example.com
Preferred contact method
*
Telephone
Email
Either
Who is this enquiry for (e.g. yourself, a friend, or a family member) who may be interested in attending?
Name of the person who may attend
*
First Name
Surname
Approximate age range
Please Select
Under 65
65–74
75–84
85+
Prefer not to say
Postcode area
*
Please provide the first part of the postcode only if preferred, for example BS22.
Is the person interested in attending currently living with dementia, memory difficulties, or similar support needs?
*
Please Select
Yes
No
Not formally diagnosed
Prefer not to say
Preferences
Which session time(s) would you or the person you’re enquiring for prefer to attend?
Which service option are you interested in?
*
Full Day Club session, 10:00am to 4:00pm
Day Club session, 10:00am to 2:00pm
Day Club session, 12:00pm to 4:00pm
Peripatetic outreach support
Trial session
Transport
Lunch
Not sure yet / would like to discuss
Our Service offer is currently available on Wednesdays only. Would Wednesdays usually be suitable?
*
Yes
No
If Wednesdays are not suitable, or you are unsure, which other days may be of interest in the future?
*
Monday
Tuesday
Thursday
Friday
Weekends
What are you hoping the person attending may gain from this service?
*
For example, social interaction, meaningful activity, routine, confidence, carer respite, or trying something new.
Is there anything important we should know before contacting you?
Please tell us briefly about any key support needs or considerations.
*
Please keep this brief at this stage. For example, mobility, communication, personal care, eating and drinking, medication, anxiety, behaviour, transport or anything that may affect whether the Day Club is suitable. We will ask for more detailed information later if you decide to proceed.
Are there any immediate risks or urgent issues we should be aware of?
*
No
Yes
Unsure / prefer to discuss
If yes, please provide brief details:
Terms and Conditions
Consent and next steps
Please confirm:
*
I understand that this is an expression of interest only and does not guarantee a place.
I understand that AYC will use the information provided to contact me about the services on offer and other related support options.
I understand that more detailed information will be required before someone can attend the service.
Where I am completing this form on behalf of someone else, I confirm that I have appropriate authority to do so, or that I am making this enquiry in their best interests.
Would you like to receive updates regarding all AYC services?
Please Select
Yes
No
Send expression of interest
Should be Empty: