Age Connects Torfaen TradesCeramicsHome Made FoodsThe Repair Shop (including upcycling)Cake MakingGrowing and managing your allotmentJewellery Making
Date of Birth
Next of Kin / Emergency Contact
Address (Next of Kin)
Contact Number (Next of Kin)
Relationship to Next of Kin
Do you have any medical conditions that we should be aware of? (e.g. stroke, heart disease, dementia, mental health issues, diabetes, allergies)
Have you received your COVID Vaccinations?
How would you bests describe your ethnic origin?
What is your marital status?
MarriedSingleDivorcedWidowerSeparatedPrefer not to say
Current employment status:
Employed Full TimeEmployed Part TimeRetiredMade RedundantLong Term UnemployedClaiming Benefits
To assist with your referral, we require your consent to store information about you, the law (General Data Protection Regulations) states that we must receive your consent to do this. All details will be treated confidentially. The Stepping Stones project is funded through the UK Community Renewal Fund, therefore some evaluation data will be shared with third parties, however it will be anonymised. Please read the following sentence and, if you consent, please check mark the box below:
I give my consent to Age Connects Torfaen to record personal information about myself or person I am representing.
The Widdershins Centre
East Avenue, Sebastopol
Pontypool, Gwent, NP4 5AB
Tel: 01495 769264
Registered Charity No: 1172466
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