Referral Form

Name(Required)

First Last

Please provide at least one of the contact details below. If you are referring for someone else, or want to find out more about volunteering with Furness For You, please select from the options below, and use the text area to add your query.(Required)

I am referring myself

I am referring someone else

The following contact and location details need to be those of the person being referred to the service, including if you’re referring on behalf of someone else. If you are referring on behalf of someone else and they don’t have any immediate contact details, please just let us know in the ‘In your own words box below’.

Email(Required)

Name(Required)

First Last

If you are referring someone else please enter their name above.

Mobile(Required)

Landline

Date of birth(Required)

Address(Required)

Where do you currently live *(Required)

In your own words please can you explain your experience of loneliness/social isolation, or what you know about those of the person you are referring to the service. At this point of the process, you can share as much or as little as you feel comfortable with.(Required)

Are you currently in a voluntary role with any organisation/community group?(Required)

Data Protection: For the purposes of General Data Protection Regulations 2018, the data controller in respect of your personal data is Cumbria CVS. Your data will be used to administer this Furness For You referral or volunteering enquiry. Your information will only be shared with Furness For You partners and will not be shared with any other third party without your prior permission and will be disposed of in line with our Document Retention Policy. As regards sending information regarding our services, we will do this until such time as you ask us not to.

Privacy Policy(Required)

I have read the Privacy Policy

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