Day Club interest form

Please fill in this form if you are interested a place at one of our day clubs in Wiltshire for yourself or for someone you care for. Please note our clubs are based in Trowbridge, Devizes, Warminster and Salisbury and serve those towns and the surrounding villages.

If you would like any help filling in the form or prefer to talk by phone, please call 01225 776481 to be put through to the relevant club.

As a charity we charge a subsidised rate of £62 per day, including lunch and all refreshments. You may be entitled to financial assistance from Wiltshire Council to help with this.

I'm referring for *
Your information
What is your relationship to the person you are referring
Does the person know that you are making this referral?
Who should be contacted about the referral?
Your information
DD/MM/YYYY
Do they have a diagnosis of dementia?
Do you live alone?
How would you like us to contact you?
Which is your closest Day Club?
About the person being referred
DD/MM/YYYY
Do you have a diagnosis of dementia?
Do they live alone?
Which is their closest Day Club?
Please tell us about anything else that you think is relevant to this referral.