Sign up to be Age and Dementia Friendly

Sign up to be Age and Dementia Friendly
The purpose of this form is to collect the information we need to process your application as an Age and Dementia Friendly organisation.
Name of your organisation, service or business*
This is the name that will appear on the online list of organisations that have signed up
Website
This will appear on the online list of organisations that have signed up
What does your organisation do?*
Brief summary (eg 'We are a cafe' or 'We are a petrol station'). Please tell us if you already do things specifically with or for older people.
Which sector does your organisation work in?

Commercial / private sectorPublic sectorThird sector / voluntary sector
Please tick any areas where your organisation is active:

Arts, culture and leisureBusinessDigitalEducation, children, young people and studentsEmergency servicesEnvironmentHealth and social careHousingOlder peopleTransportVoluntary, community and faith group
What is your organisation going to do to be more Age Friendly?

Please be specific and ensure any actions are measurable and achievable over the next 12 months. Here are some examples of things you might do:

- Join the Come in and Rest Scheme and offer a seat to an older person who needs it
- Identify an Age Friendly Ambassador within your staff team
- Ensure your printed materials are in large clear fonts
Age Friendly Actions*
What Age Friendly actions are you going to take?
What is your organisation going to do to be more Dementia Friendly?

Please be specific and ensure any actions are measurable and achievable over the next 12 months. Here are some examples of things you might do:

- Offer a Dementia Friends session for your staff
- Ensure signs are fixed to the doors they refer to, not adjacent to them
- Signpost customers to places where they can get dementia support
Dementia Friendly Actions*
What Dementia Friendly actions are you going to take?
Your contact details

We'll use your address to send out your stickers and on our online map of Age and Dementia Friendly locations. If you do not have a public venue, or you have more than one venue you would like adding to the map, please email sarah@opforum.org.uk with the details.
Contact first name*
Contact last name*
Phone number*
Address 1*
Address 2
Town or city*
Postcode*
Main contact email*
We will use this email address to contact your organisation.
The Friendly Communities team will send a monthly newsletter and occasional relevant information to the main contact email.

We will use the contact information you provide to contact you again regarding your Age and Dementia friendly status and to ask for feedback to monitor and evaluate the programme.
Email for Friendly Communities bulletin only
If you want the bulletin sending to a different email address than the main contact, please add it here.
Leeds Directory

Organisations that are signed up can also be listed on Leeds Directory as Age and Dementia Friendly places. This is a Leeds City Council online source of information about a range of local community care, support services and activities.
Would you like to be contacted by Leeds Directory about a free listing in the directory or to have the Age and Dementia Friendly logos added to your current listing?*

YesNo
Stickers

Window stickers are available! We will provide one Age Friendly and one Dementia Friendly window sticker per venue. If you have more than one venue or several public entrances to your venue then please contact sarah@opforum.org.uk to request additional window stickers.

Stickers

	1	2	3	4	5
Age Friendly stickers
Dementia Friendly stickers

Join Come in and Rest
If you would also like to join Come In and Rest please tell us here. We will provide one Come in and Rest window sticker per venue. If you have more than one venue or several public entrances to your venue then please contact sarah@opforum.org.uk to request additional window stickers.

We'll include your contact address on our online map of 'Come in and Rest' locations. If you would like to use a different address please fill it in below.

Come in and Rest stickers

	Yes	No
Join Come in and Rest

Come In and Rest address 1
Address 2
Town or city
Postcode

complete Come in and Rest stickers
Age Friendly and Dementia Friendly sign up

Yes
Thank you for completing this form and choosing to be Age and Dementia Friendly.
Should be Empty:

Sign up to be Age and Dementia Friendly

What is your organisation going to do to be more Age Friendly?

What is your organisation going to do to be more Dementia Friendly?

Your contact details

Leeds Directory

Stickers