ART BY POST REFERRAL FORM ON BEHALF OF AN ORGANISATION

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We’re delighted you’re interested in taking part in Art by Post on behalf of your organisation.

We have launched this scheme to connect with people living with dementia, and other chronic health conditions, who are isolated under the current social distancing measures.

By completing this form, you are agreeing on behalf of your organisation to receive more information about Art by Post.

After we receive your application, we will follow up with an additional form to collect monitoring information about your group which will help us ensure we are reaching diverse communities.

If you would like to know more about how we use your data, our data policy is here: [ https://www.southbankcentre.co.uk/policies/privacy ]

Your first name *

Your last name *

Your role *

Name of organisation *

First line of postal address *

Second line of postal address

Town or city *

County *

Postcode *

Your telephone number *

Your email address *

Please tell us what type of organisation you are by ticking the boxes that best describe your work. *

Social care

Primary care

Secondary care

Extra care housing / supported living

Care home

Charity working with older people

Charity working within mental health settings

Charity working within health settings

Community or voluntary organisation

Arts organisation

Other (please give details)

Other:

Required

If ‘other’, please give us more information below

Have or your organisation taken part in Art by Post before? *

Yes

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