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Application form for

Voice for Life Group

Lewisham Speaking Up

At The Albany, Douglas Way, Deptford

If you need support to fill in this form please ask for help

Information about you:Your Name:

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Your Address:

Your Telephone number:

Tell us if you are taking any medication, any medical conditions and allergies:

Tell us what help you may need during the

group

Have you been part of a speaking up group before? If yes, which

one?

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What would like to get from the group?What would you like to change in your

life?

Do you agree to respect the other members and their

privacy (keep confidentiality)?

I find it hard to speak up when (tick as needed):

□ When I need something□ When I don’t like something□ When I feel angry or upset □ When I feel worried □ When someone hurts me or is mean to me□ When I don’t know how to say what I want

Who should we contact in case of emergency?

Their name & relation to you

Their contact details

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Thank you for filling in this form

If you would like to know more or have any questions please call:

Alina Apopei (group coordinator)

Tel: 020 8692 1862

Please return this form to Alina or post it to:

Address: Voice for Life - Lewisham Speaking Up The Deptford Albany Douglas Way, Deptford London SE8 4AG