Calderdale LibrariesREFERRAL FORM

Library:

Postcode: Volunteer:

Date: ------------------------------------------------------------------------------Clients Name: -----------------------------------------------------------------------------Address: ----------------------------------------------------------------------Postcode: ---------------------------------------------------------------------Tel no: ---------------------------------------------------------------------------Email: --------------------------------------------------------------

Self referral yes no

Person referring: ----------------------------------------

Organisation (if applicable): -------------------------------------------Please tick: age 55-65 …. 66-75 ….. 76-8 ….. 85 and over …

AGEUK Calderdale & Kirklees volunteers are here to help with your basic IT needs.

If you could outline what you would like to achieve in this session our volunteers can prepare any

information they might need before meeting with you so as to make your sessions as effective as

possible. Thank you.

Please state what you would like to achieve::…………………………..

………………………………………………………

Volunteer comments: ……………………………………………………………

* Please return completed form to Age UK Calderdale & Kirklees, 4-6 Square, Woolshops, Halifax, HX1 1RJ

Admin2014/ACuthbert/DigitalInclusion/V1

Age UK Calderdale & KirkleesChoices Centre4-6 SquareWoolshops t 01422 399 830Halifax e enquiry@ageukck.org.ukHX1 1RJ www.ageuk.org.uk/calderdaleandkirklees Age UK Calderdale & Kirklees is a registered charity (1102020) and a company limited by guarantee. Registered in England and Wales number 5013745