Online referral form

Name of potential member:

Date Of Birth:

Address:

Post code:

Email:

Home tel:

Mobile:

Which Studio are you interested in attending:

How did you hear about Studio Upstairs?

Referral details:

Referral contact

Name:

Position:

Address:

Postcode:

Telephone:

Email:

Funding of membership fees

Funding is not confirmed, though has been applied for:
YesNo

Funding is confirmed and it will be through:

Name of Funding Body / Local Authority:

Self Funding - are you in receipt of any of the following benefits:
NonePersonal Independence Payment: Enhanced ratePersonal Independence Payment: Standard rateDisability Living AllowanceEmployment and Support AllowanceJob Seekers AllowanceCarers Allowance

Additional information: