Join Us - Silverline Memories

Join Us or Refer Someone to Us

Many of our services, such as our support groups, require membership. If you would like to join, or would like to refer someone to us, all you have to do is fill in as much of the form as you can manage, click the submit button and a member of our staff team will be in touch.’.

And there's nothing to pay - Silverline Memories is funded entirely via sponsorship funding and donations.

Referral form

Section 1
Information about the person you are referring
Name*
Date of birth
DD slash MM slash YYYY
Home telephone
Mobile telephone
Marital Status
Gender
- M
- F
- Other
- Prefer not to say
Address
Please include post code

Address Line 1 Address Line 2 City County Post code
Email
Nationality
Religion (if any)
Does this person have any special dietary requirements?
Does this person have any medical conditions/ disabilities?*
e.g. vascular dementia, Alzheimer’s etc.
Section 2
Information about the person making the referral (if you are self-referring please write n/a and go to section 3)
Name of referrer
Relationship to the person being referred
Address
Please include post code

Address Line 1 Address Line 2 City County Post code
Telephone number
Email
Reason for referral
If you are the person’s Carer, we’d love to add you to our birthday list, please give your dob here:
DD slash MM slash YYYY
Section 3
Additional Information about the person named in Section 1
Please give details of other services involved with this person
Such as Social Worker, Care Agency, etc.
Is there anything else you'd like to tell us about this person?
Such as behaviours, symptoms, mood, emotional state, day-to-day life, family circumstances, etc. It can also be helpful to include information about their previous occupation, hobbies, interests, etc.
In an emergency who would this person like us to contact?
Name
Relationship
Telephone number
Email
Finally...
Do you consent to us taking photographs/videos that might be used for marketing purposes?*
- Yes
- No
How did you hear about Silverline Memories CIO?
Comments
This field is for validation purposes and should be left unchanged.

Are you thinking about writing or changing your Will? You can do it completely for free by visiting the Free Wills site.

And if you include a pledge in your Will to Silverline Memories, no matter how small, you can keep helping us to improve the lives of people with dementia.

Silverline Memories, 177B Kirkwood Drive, Kenton Retail, Newcastle upon Tyne, NE3 3BE

Registered charity no 1163582

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Join Us or Refer Someone to Us

Referral form

Section 1

Section 2

Section 3

In an emergency who would this person like us to contact?

Finally...

Would you like to receive our newsletter?

Would you like to receive our newsletter?