Join a network near you

Your details

Your name*

First Middle Last

Your date of birth*

Your gender*

Male
Female
Other

Nationality*

Your email address*

Your phone number*

Your home address*

Address Line 1 Address Line 2 City County Postcode

Emergency contact name*

Emergency contact's phone number*

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

Please tick to consent*

Please tick this box to give Love4Life consent to contact your emergency contact

More about you

Are you on Facebook?*

Yes
No

You can upload a photo of yourself if you want to

Max. file size: 64 MB.

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?*

Hampshire
London
Coventry
Southampton City
Online (If we are not in your location you can choose to join the online only membership)

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

Reference request

To become a member of Love4Life, you are required to provide a reference from someone who knows you in a professional manner. This could be a social worker, a college lecturer, your GP, an employer, or your support worker. We will ask them to confirm that you are who you say you are, that you have a disability, and that, to the best of their knowledge, you have no criminal convictions or cautions. Please provide the details of this person below.

Referee name

First Last

Referee email address

Referee phone number

Referee relationship

Please tick to consent to Love4Life contacting your reference*

Yes
No

Where did you hear about Love4Life?*

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

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.

Consent

I agree to the privacy policy.

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