Pupil Pals referral form

Omega is working with primary schools to deliver Pupil Pals, a free befriending service in which socially isolated and lonely clients receive regular cards and pictures made for Omega by creative children. 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:
Additional information - 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

Client's emergency contact

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