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Student Friends referral form

Omega is working with secondary schools and colleges to deliver the free befriending service, Student Friends. Via Omega, socially isolated and lonely clients receive supportive letters from students. Clients can also write back, if they wish. Complete this form to refer yourself or someone you know.

Section 1 · About the referrer

If you are completing this form for yourself, go straight to: Section 2 · About the client.
Referrer name:

Section 2 · About the client

Client name:(Required)
Address
Date of Birth:
Would you prefer a student who is:
Additional information - tick all that apply:
Your general hobbies and interests - tick all that apply:
Please select which ethnicity you identify with:
Would you describe your sexual orientation as:
Consent to storage of personal information on Omega's database - tick required:(Required)
Select to subscribe to the Omega Newsletter by:
DD slash MM slash YYYY

Section 3 · Client's emergency contact

Emergency Contact name:
This field is for validation purposes and should be left unchanged.

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OMEGA
London House, Town Walls
Shrewsbury, SY1 1TX
01743 245 088 | info@omega.uk.net
Registered Charity No.1120322
Registered Company No.6196052

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