The Marigold Centre Ltd.
62 Avenue Road, Westcliffe on Sea, Essex, SS0 7PJ
TEL: 01702 840699
Membership registration
Name
Address
Line 1
Line 2
Line 3
Post Code
Phone Numbers
Home
Mobile
Email
Emergency contact name
Parent/guardian
Home phone
Mobile phone
Emergency contact name
Doctors name
Surgery Phone Number
Out of hours Phone Number
Days you wish to attend
Monday
Tuesday
Wednesday
Thursday
Friday
General information we need to know
Level of disability and mobility
Medication that may need to be administered
Level of personal care required
Allergies
Diet requirements
Fears or phobia
Any not listed
General information and interests that it's nice to know
Things that make you happy or calm
Things that may upset you
Favourite film /TV show
Favourite music
Favourite food and drinks
Have you any pets
Places you like to visit
Favourite activities
Brothers and Sisters
Ambitions
What would you like to achieve
Any other information you feel we need to know