Gardening | The Helpful Bureau - Home Support for the elderly and disabled in Broxtowe since 1975

Apply for Home Support

Referrer Name *

First

Last

Address *

Post Code *

Details of Request *

Referrer Name *

First

Last

Phone Number *

Relation to Client *

Date Requested *

Additional Info

Apply now for help with decorating.

Name *

First

Last

Phone Number *

Address *

Postcode *

Details of Request

Referrer Name *

First

Last

Phone Number

Relationship to the Client

Any Other Info

Apply now for help with odd jobs.

Name *

First

Last

Phone Number *

Address *

Postcode *

Details of Request *

Referrer Name *

First

Last

Phone Number *

Relationship to the Client *

Any Other Info

Website

Apply now for help with gardening.

Name *

First

Last

Phone Number *

Address *

Postcode *

Details of Request *

Referrer Name *

First

Last

Phone Number *

Relationship to the Client *

Any Other Info

Message

Apply now for the Befriending Scheme

Name *

First

Last

Phone Number *

Address *

Postcode *

Referrer Name *

First

Last

Phone Number *

Relationship to Client *

Any Other Info *

Message

Book Tansport Via Car

Name *

First

Last

Adress *

Post Code *

Phone Number *

Mobility *

Do you require wheelchair access? *

Do you have a Blue Badge? *

Will you be accompanied by another person? *

Are you booking on behalf of the service user? *

If yes, fill in full name *

First

Last

Phone Number *

Relationship to Client *

Leaving Date *

Leaving Time *

Return Date *

Return Time *

Destination Address *

Destination Postcode *

Appointment Time *

Website

Book Transport Via WAV

Name *

First

Last

Adress *

Post Code *

Phone Number *

Mobility *

Do you require wheelchair access? *

Do you have a Blue Badge? *

Will you be accompanied by another person? *

Are you booking on behalf of the service user? *

If yes, fill in full name *

First

Last

Phone Number *

Relationship to Client *

Leaving Date *

Leaving Time *

Return Date *

Return Time *

Destination Address *

Destination Postcode *

Appointment Time *

Website

Boxed Meal Service Form

Name *

First

Last

Phone Number *

Address *

Post Code *

Additional Info

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Driver Application Form

Name *

First

Last

Address *

Postcode *

Date of Birth *

Phone Number *

Email *

Next of Kin *

Next of Kin's Phone Number *

Do you have a long- term illness or disability? *

Do you have any special requirements? *

If yes, please give details...

Would you be able to drive... *

Your own car
Our wheelchair accessible vehicle
Our Minibus

Please highlight relevant experience for the role, including training courses... *

What days are you available? *

Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM

We would like to reassure you that your details are safe with us and will never be released to a third party organisation without your consent. *

I give my consent for my data to be used for the purpose of processing this aplication.

Office Volunteer Application

Name *

First

Last

Address *

Post Code *

Date of Birth *

Phone Number *

Email *

Volunteer Role *

Next of Kin *

First

Last

Next of Kin's Phone Number *

Do you have a long- term illness or disability? *

Do you have any special requirements? *

If yes, please give details...

Please highlight relevant experience for role, including training courses. *

What days are you available? *

Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday Am
Thursday PM
Friday Am
Friday PM

We would like to reassure you that your details are safe with us and will never be released to a third party organisation without your consent. *

I give my consent for my data to be used for the purpose of processing this aplication.

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Trustee Enquiry Form

Name *

First

Last

Email *

Phone Number *

Message *

Message

Befriender Enquiry Form

Name *

First

Last

Phone Number *

Message *

Message

Trip Booking Form

Name *

First

Last

Phone Number *

Mobility *

Which trip(s) would you like to book? *

Tuesday 7th April – National Memorial Arboretum £10
Tuesday 5th May – Amerton Farm, Stafford £10
Tuesday 2nd June – Moreton-in-Marsh £12
Tuesday 7th July – Skegness £TBC

Additional Info

Please pop into the office to pay or send a cheque made payable to The Helpful Bureau. *

I agree to pay for any and all trips booked via this form using the method requested by The Helpful Bureau.

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Activity Booking Form

Name *

First

Last

Phone Number *

Mobility *

Which activities would you like to book? *

Footcare with Lisa - £15 (30 minutes)
Turn Back Time Tuesdays - Free
Grumpy Old Men's Club - Varies
Movement to Music - £3.50
Lunch Club & Activities - £5

Additional Info

Please pop into the office to pay or send a cheque made payable to The Helpful Bureau. *

I agree to pay for any and all trips booked via this form using the method requested by The Helpful Bureau.

Client Registration Form

Client Name *

First

Last

Title *

Mr
Mrs
Miss
Ms

Date of Birth *

Contact Telephone Number *

Email Address

Current Residential Address *

Post Code *

Who do you live with? *

Alone
With Spouse
With Family
Other Living Arrangements

Mobility *

No mobility issues
Wheeled walker
Electric wheelchair
Uses a stick
Manual wheelchair
Mobility scooter

Do you have a blue badge? *

Do you consider yourself to have a long term progressive illness or disability? *

If yes, please give brief details. *

Emergency Contact Name *

First

Last

This could include family, doctor, social care, other voluntary organisations.

Emergency Contact's Relationship to Client *

Emergency Contact Address *

Emergency Contact Telephone Number *

Emergency Contact Email

Where did you hear about The Helpful Bureau? *

Internet
Medical Professional
Event
Advert
Family/Friend

What age group do you fall in to? *

18-49
50-64
65-74
75-84
85-90
90+

What is your gender? *

Male
Female

What is your religion? *

Christian
Sikh
Buddhist
Muslim
Hindu
Jewish
None
Other
I'd rather not say

How would you describe your ethnic group? *

White British
Black/African
Indian
Gypsy, Romany
White Irish
Mixed African
Pakistani
Irish Traveller
White Other
Black Caribbean
Bangladeshi
Chinese
Mixed Other
Mixed Caribbean
Asian Other
Mixed White & Asian
Black Other
Other Ethnic Background
I would rather not say

Would you like anyone to contact you about the following?

Small DIY Job
Decorating
Gardening
Domestic Support
Volunteer Transport Scheme
Foot Care
St Helen's Friendship Group
Keep Fit
Day Trips
Craft Club
Lunch Club
Grumpy Old Men's Club
Befriending

If you wish to receive information about services provided, please tick the box.

Occasionally we would like to contact you about upcoming events that we think may be of interest to you. If you wish to receive information about the services provided, please tick yes.

If you do not wish to have your image printed, please tick the box.

At times we may take photos/videos and this might include (but is not limited to), the right to use them in our printed and online publicity, social media, press releases and funding applications.

I agree to The Helpful Bureau retaining my data as described below. *

The Helpful Bureau will hold your personal details (data) with your “Consent”. The GDPR gives you: the right to be informed; the right to have access to your data; the right to have mistakes rectified; the right to have it erased (to be forgotten); the right to restrict the use of your personal data; the right to object to the use of your personal data; and the right to ask for an automated decision to be reconsidered by a human. We would like to reassure you that your details are safe with us and will never be released to a third party without your prior consent.

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Donating to The Helpful Bureau

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