Online referral form

    Name of potential member:

    Date Of Birth:

    Address:

    Post code:

    Email:

    Home tel:

    Mobile:

    Which Studio are you interested in attending:

    Which Group 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 Local Authority/ NHS Trust:

    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: