Join Love4Life

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Your full name, including middle names*

Date of Birth*

Your gender*

Male

Female

Other

Nationality*

Your email address*

Phone*

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Address*

Emergency Contact Name*

Emergency contact's phone number*

Please tick this box to give Love4Life permission to contact your emergency contact

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More about you

Are you on Facebook?

Yes

No

What are your disabilities?

Learning disabilityAutismOther

If other, please specify

How does your disability affect you?*

Do you have any mobility needs?*
Ie do you use a wheelchair or have difficulty with stairs

Do you require any additional support?

Yes

No

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More about you

Do you have any communication support needs?
ie sign language, makaton, understanding other people

Do you require medication?
ie epilepsy, anxiety

Are you looking for friendship?

Yes

No

Are you looking for a relationship?

Yes

No

If yes, are you looking for:
(You can tick more than one)

BoyfriendGirlfriendOther

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More about you

Which network would you like to join?

What do you like and what are you interested in?*

How will you travel to Love4Life events or dates?*

Do you have any criminal convictions or cautions, spent or unspent?

Yes

No

If yes: Please provide full details of the incident (s), what the offence was, and what sentence you received?

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Reference Request

To become a member of Love4Life, you must give us a reference from someone who knows you, who is not a friend or family member.
This could be a social worker, a college lecturer, your GP, an employer, or your support worker. We will ask them to confirm that you are who you say you are, that you have a disability, and that, to the best of their knowledge, you have no criminal convictions or cautions.
Please provide the details of this person below.

Referee Details

Referee First Name*

Referee Last Name

Referee email address*

Referee phone number*

Who is the referee to you*
ie your GP, your support worker

Please tick to consent to Love4Life contacting your reference.

Yes

No

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Your information

Where did you hear about Love4Life?

I give my consent for FitzRoy and Love4Life to keep my information while I am applying to be a member and for as long as I am a member of Love4Life.

Consent
‍I agree to the privacy policy
‍
Love4life will keep this information while your application is being processed and as long as you are a member of Love4life. Love4Life will retain your information for up to 12 months after you choose to leave Love4Life and will write to you to confirm the cancellation of your membership and invite you to provide feedback on why you've chosen to leave Love4Life. If your application is unsuccessful, your details will be destroyed.

Love4Life membership application form

Please note this process will take upwards of 10 minutes to complete

More about you

More about you

More about you

Reference Request

Referee Details

Your information

Thank you for signing up!

Name thank you for your interest in Love4Life.

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