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Letterbox referral form
Please enter your details
Name
(Required)
Dr
Miss
Mr
Mrs
Ms
Prof.
Rev.
Mx
Prefix
First
Last
Address
(Required)
Street Address
Address Line 2
City
Please Select
Aberdeenshire
Angus/Forfarshire
Argyllshire
Ayrshire
Banffshire
Bedfordshire
Berkshire
Berwickshire
Blaenau Gwent
Bridgend
Buckinghamshire
Buteshire
Caerphilly
Caithness
Cambridgeshire
Cardiff
Carmarthenshire
Ceredigion
Cheshire
Clackmannanshire
Conwy
Cornwall
Cromartyshire
Cumberland
Denbighshire
Derbyshire
Devon
Dorset
Dumfriesshire
Dunbartonshire/Dumbartonshire
Durham
East Lothian/Haddingtonshire
Essex
Fife
Flintshire
Gloucestershire
Gwynedd
Hampshire
Herefordshire
Hertfordshire
Huntingdonshire
Inverness-shire
Isle of Anglesey
Kent
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Lancashire
Leicestershire
Lincolnshire
Merthyr Tydfil
Middlesex
Midlothian/Edinburghshire
Monmouthshire
Morayshire
Nairnshire
Neath Port Talbot
Newport
Norfolk
Northamptonshire
Northumberland
Nottinghamshire
Orkney
Oxfordshire
Peeblesshire
Pembrokeshire
Perthshire
Powys
Renfrewshire
Rhondda Cynon Taff
Ross-shire
Roxburghshire
Rutland
Selkirkshire
Shetland
Shropshire
Somerset
Staffordshire
Stirlingshire
Suffolk
Surrey
Sussex
Sutherland
Swansea
Torfaen
Vale of Glamorgan
Warwickshire
West Lothian/Linlithgowshire
Westmorland
Wigtownshire
Wiltshire
Worcestershire
Wrexham
Yorkshire
County
Postcode
Date of Birth
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Phone
(Required)
Mobile
Email
Referrer (if not self-referring)
Name
Phone
Email
Relationship
If professional referring, employer
How did you hear about Omega?
Your Emergency Contact
Name
(Required)
Phone
(Required)
Email
Relationship
(Required)
A bit about you
Would you prefer a pen pal who is
Male
Female
Don't mind
Would you consider being matched to a younger pen pal befriender
Yes
No
Please tick which of these apply to you:
Additional information
(Required)
Lives alone
Over 75
Bereaved
Caregiver
Former caregiver
Socially isolated
Your general hobbies and interests (tick all that apply)
(Required)
Animals
Arts/Crafts
Cooking/Food
Culture/History
Family
Gardening
Music
Outdoors
Reading
Sports/Fitness
Please write down some specific details about your hobbies and interests; we need this information to match you up with an appropriate pen pal
Significant life event(s) / information
Please tick which ethnicity you identify with
Asian
Asian British
Black
Black British
Mixed
Other
White
Would you describe your sexual orientation as
Heterosexual
Gay/lesbian
Bisexual
Other
Prefer not to say
How did you hear about Omega?
Storing of my information on Omega's databases
(Required)
I agree to receiving Omega communications and to the storing of my information on Omega's databases
Omega Newsletter
I would like to receive Omega’s e-newsletter to hear news about Omega’s vital work to keep older people connected and living well
Date
MM slash DD slash YYYY
Comments
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