Become a member

First Name (required)

Last Name (required)

Address Line 1 (required)

City (required)

Postcode (required)

County (required)
West Yorkshire

Country (required)
United Kingdom

Gender
—Please choose an option—MaleFemaleOther

Phone Number (required)

Living alone? (required)
YesNo

If no, who else lives at the property?

Email (Confirmation will be sent here, if provided)

Reason for Referral (required)
—Please choose an option—Access to Schemes ServicesBereavementNeeding Support because of healthRequiring Information/AdviceShared care as part of networkSocial IsolationWanting to volunteer

Religion
—Please choose an option—ChristianHinduJewishMuslimSikhOtherPrefer not to say

Ethnic Origin
—Please choose an option—White - BritishWhite - IrishWhite - OtherGypsy/Irish TravellerBangladeshiChineseIndianPakistaniAsian - OtherAfricanCaribbeanWhite and Black AfricanWhite and Black CaribbeanBlack - OtherArabAny otherPrefer not to say

Please tick all that apply
Alzheimer'sAnxietyArthritisAsthmaCancerCOPDDementiasDepressionDiabetesEpilepsyHearing ImpairedHeartHigh Blood PressureLearning DisabilitiesMobilitySensory ImpairedSight ImpairedStrokeOther

Neighbourhood
—Please choose an option—AusthorpeColtonCrossgatesHaltonKillingbeckManstonPendasTemplenewsamWhitkirkYork Rd.Out of Area

Ward
—Please choose an option—Crossgates and WhinmoorKillingbeck and SeacroftTemple NewsamOut of area

Emergency Contact name and number (required)

Please give details of why you would like to become a member and how you are hoping to benefit from our services (required)