Register to join the Bear With Me social group

    To register an interest in becoming a member of the Bear With Me social group for autistic adults, please complete and submit this form – our team will contact you.

    Name

    Address

    Postcode

    Telephone number

    Email address

     

    Which council area do you live in? *


    If you answered Other above, please give the council name

     

    Referral from (how did you find out about/who told you about our service?)

     

    Additional needs (please tick all that apply) *

    If you answered Other above, please give details

     

    Support/social workers’ details (if applicable):

    Name

    Telephone number

    Email address

     

    Voluntary Donation to the running costs of the Bear With Me group (please tick to indicate if you have made a donation)

     

    I consent to Autism Berkshire storing my details on a secure database and contacting me about (please tick all that apply)

     

    I am happy to be contacted by (please tick all that apply):

    Your confirmation:

     

    Privacy and data protection
    Personal information you submit using this form will be treated as confidential and stored securely. See our privacy policy for more information.