Online Registration Form

Older people can request a paper copy of our Registration Form by phone on 020 8539 6976.

By completing and signing our form for free registration as a service user, customer, or carer you can access:

• Information about our services and activities
• Regular updates
• Priority access to book events
• Practical support
• Information to contact service providers to meet every day needs when you use one or more of the active lifestyle options

To apply for free registration online please complete your details below.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Title – please specify

Email *

Address

Postcode

Telephone Number

Mobile Number

Gender

Age group40-4950-6465-79Other

Do you have a Disability or Long-term illness?YesNo

Do you require information in Large print?YesNo

Are you a Carer?YesNo

EthnicityWhite BritishAsian BritishBlack BritishMixed HeritageOther

Emergency Contact Details – Name, Address, Relationship, Telephone Number, Mobile Number, Email

Tell us about activities you like to take part in and ones you want to try

Privacy Policy Agreement *

• I have read the Privacy Policy at https://mbswellbeingcic.com/privacy-policy/

For Office Use:

Submit

If you wish to cancel your free registration you can contact us by phone or in writing.