Marmalade’s Christmas Cheer

Christmas Day Guest Referral Form

Referral details

Referrer's Name (required):

Referrer's Email (required):

Referrer tel number (required):

Referral organisation:

How did you find out about us?

Would the person (guest) you’re referring otherwise be on their own on Christmas Day?
YesNo

Has the person consented for Marmalade Trust to contact them? (required)

Guest’s details:

Full name (required):

Tel number (required):

Address (required):

Date of Birth:

Email:

GP surgery:

Next of Kin details:

Full name:

Tel number:

Relationship to guest:

Email:

Mobility/Health information:

Mobility/transfer ability:

Any other health concern? (e.g. sensory impairment/long-term care)

Any other comments/issues we should be aware of?

Please note that a Marmalade health professional calls each guest prior to Christmas Day to carry out a short telephone health and risk assessment. In some circumstances a home visit may be arranged. We will only use your data in conjunction with Marmalade's Christmas Cheer Event.