Join a network near you

Your details

Your name*

First Middle Last

Your gender*

Male
Female
Other

Nationality*

Your home phone

Your mobile phone

Secondary number*

Please provide a secondary number of someone we can contact if we cannot get hold of you.

Your email address*

Are you on Facebook?*

Yes
No

You can upload a photo of yourself if you want to

Max. file size: 64 MB.

Your home address*

Address Line 1 Address Line 2 City County Postcode

Your date of birth*

Reference request

You will be asked to provide two references of people you know in a professional manner. This could be a social worker, college lecturer, your GP, or an employer. There is a link in your contract that you can use to send to your references; you will be sent on submission of this enquiry form.

Please tick to consent*

Yes
No

More about you

What are your disabilities?*

Learning disability
Autism
Other

If you selected 'other', please provide more details.*

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?*

Do you have any communication 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 you clicked yes, are you looking for:

You can select more than one.

Boyfriend
Girlfriend
Not sure

Which network would you like to join?*

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

Is there anything you don't like or would avoid?*

How will you travel to Love4Life events or dates?*

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

Yes
No

If you ticked yes, please explain more

Where did you hear about Love4Life?*

Other

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.

Your information*

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.

Yes

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