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

Please provide two references of people you know in a professional manner. This could be a social worker, a doctor or an employer or similar.

Please tick to say we can contact your references

Yes

Reference contact 1 name*

First Last

Reference contact 1 details*

Reference contact mobile phone number*

Reference contact email address*

How do you know this person?*

Reference contact 2 details (optional)

Reference contact mobile phone number

How do you know this person?

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

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

FitzRoy will keep this information while your application is processing and for as long as you are a member of Love4Life. If your application is not successful, or you decide to stop your membership, this information 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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