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Register with First Call 50+

If you are over 50 and live in the City of York Council area you are eligible to use 'First Call 50+' Please complete the form below to register with the York City Council First Call 50+ service. When we recieve your registration we will contact you to talk about all the services you need and to help you obtain them.

Title:	First Name:	Last Name:
Address:
Postcode:		Telephone:
Date of Birth:		Ethnic Group:
Your email address: Please confirm your email address:
Please answer the following questions by choosing 'Yes' or 'No' and tell us if you need more information
Housing & Accommodation
1.) Have you got a working smoke alarm on each floor of you home?		Yes	No	Information needed
2.) Do you have any repairs that need doing to your home?		Yes	No	Information needed
3.) Do you need any special adaptations or equipment in in the home?		Yes	No	Information needed
4.) Are you able to keep your home warm?		Yes	No	Information needed
5.) Would you like advice on home security?		Yes	No	Information needed
6.) Would you like advice on different types of accommodation that may be available?		Yes	No	Information needed
Healthcare
7.) Have you fallen in the last 6 months?		Yes	No	Information needed
8.) Would you like to know more about healthy eating, specialist diets or exercise options?		Yes	No	Information needed
9.) Do you have any concerns about your mental health? eg feelings of sadness, anxiety or memory problems		Yes	No	Information needed
10.) Do you have a disability or long term illness?		Yes	No	Information needed
11.) Would you like information on services in podietry, district nurses, eyecare, dentistry?		Yes	No	Information needed
12.) Would you like to speak to someone about hearing or sight problems?		Yes	No	Information needed
Money and Benefits
13.) Would you like any advice on money or benefits you may be entitled to?		Yes	No	Information needed
Community Groups
14.) Would you like to know more about local voluntary and community groups, clubs or social activities?		Yes	No	Information needed
15.) Are you interested in information on community transport?		Yes	No	Information needed
Support for Carers
16.) Do you recieve regular help and support from relatives and/or friends?		Yes	No	Information needed
17.) Do you provide regular help and support to relatives or friends?		Yes	No	Information needed
Other information/ support you would like?		(Please specify here)
HOUSING INFORMATION
Please select the type of Housing you live in		Owner Occupier Rented Accomodation Shared Ownership Choose from the list
If you are in Rented Accommodation or Shared Ownership please tell us who your housing provider is ( for example Council Tenant, Housing Association, Private Tenant)
Do you live alone?		Yes		No
GP INFORMATION
If you have fallen and injured yourself in the last 12 months please let us know your doctor's contact details:
Doctor's Name:		Doctor's telephone number:
Surgery Address
YOUR AREA
Which area of York do you live in?		It would help us to reach more people if you could tell us how you found our web site Please choose from the list Used a search engine Link from another site Saw address in a leaflet Someone told me the address Other
REFERAL AGREEMENT
I agree to referrals being made to organisations offering the support I have requested		Yes	No
The information you have provided will be held securely on the Age Concern AEGIS Database. Under the Data protection Act 1998 you have the right to access this information. The information you have provided may be shared only with the partner organisations involved with First Call 50+.
When you are ready to submit the form, please type this security code word into the code word box and then click on 'Submit the form' below		Security code word (Free JavaScripts provided by The JavaScript Source )
		Type code word here

For a copy of this form in your own language (eg Cantonese, Bengali, Polish, Turkish, Urdu) please telephone 01904 634061

For office use only - Referer's reference and contact details:
For office use only.