Teen and Young Adult Befriending Service Registration Form URLThis field is for validation purposes and should be left unchanged.Name(Required) First Last The Teen and Young Adult Befriending service invites young stroke survivors aged between 16 and 25 to contact us to talk with someone who gets where they are at. Our volunteers are all stroke survivors who had their stroke before the age of 25. We offer peer support either over the phone or email. Address(Required) Street Address Address Line 2 City County Post Code Please enter your email(Required) Please enter your phone number below:(Required)What is your date of birth?(Required) DD dash MM dash YYYY What was the date of your stroke?(Required) DD dash MM dash YYYY What is your current age?(Required)What is the name and address of your GP?(Required)What is the name of your emergency contact?(Required)What is your relationship with your emergency contact?(Required)Please enter the contact number for your emergency contact below:(Required)Please enter the email address for your emergency contact below:(Required)Different Strokes will match you with a befriender, who is another young stroke survivor. Our befrienders will work closely with Different Strokes Head Office (DSHO) and receive external supervision from another source. This is a confidential service between you and Different Strokes, however, if you disclose something to your befriender which gives us cause for concern that you or another individual may be at risk, then this information may have to be passed on to a third party. By signing this agreement, you understand and agree that: The service will be provided free of charge by Different Strokes Contact between yourself and your befriender will only take place at pre-arranged times. You will not attempt to contact your befriender outside of these times by phone, email, social media or any other method Different Strokes may have to divulge information to a third party where someone may be at risk Different Strokes has the consent to store your personal information. This information will be stored securely and will not be disclosed to third parties. Consent(Required) I consent that to the above and understand the conditions of the agreement as outlinedFor people aged under the age of 18, parental consent for this service must be given by a parent of guardian – enter details of this person below: Name First Last Please enter your parent or guardian's phone number below:(Required)Please enter your parent or guardian's email address below:(Required) Δ
