Referrer's Name (required):
Referrer's Email (required):
Referrer tel number (required):
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)
Full name (required):
Tel number (required):
Date of Birth:
Relationship to guest:
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.
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