Buddy Application Form

If you want a Buddy allocated to you, what do you want to entrust with them?

Just your contact details (address and telephone number) Set of keys to your property to hold in case they need to check on you Your next of Kin information, should they need to reach them on your behalf Medical information Religious Instruction or Contacts

If you only want your Buddy to have just your own contact details, would you like the more 'sensative' information (such as spare key, next of Kin information etc) held on a database, that could only be accessed in case of Emergency? (This is held in a locked file with Madeira Active)

Opt in Opt Out Not sure, want to know more

Do you have any family members living in Madeira?

Yes No

Do you have any pets?

Cats Dogs Other pet More than one pet

If you have pets please let us know how many

This section is about being a Buddy to someone with pets

Do you have any allergies to animals? Would you be willing to take on responsibility for your Buddy's Pets, should your Buddy need to go to hospital (as an example). This is to feed them at the owners own home. And is not a responsibility to assume as pet sitting service if on holiday. I am not willing to look after someone's pet's even if it is an emergency

If you are a pet owner, do you already have something set up (in case of an emergency) for someone else to come in and look after your pets?

Yes No Other

If you are allocated a Buddy, to you agree to the following?

To maintain a regular mode of contact that you have mutually agreed with your Buddy To respect your Buddy and not expect your Buddy to do anything more than what you agree on To inform your Buddy when you are away on holiday or not in your usual living space To only contact your Buddy in an emergency situation (unless you have arranged daily communication) To respect their privacy as they respect yours if your Buddy is reciprocal

If you are a Buddy to someone else, do you agree to the following?

To respect the contact wishes of my Buddy To be trusted with 'sensative' information that your buddy may give you To be trusted that if you are a key holder or hold anything of importance on behalf of your Buddy, that you keep it safe To inform your Buddy and Madeira Active when you will be away, or no longer wish to be a Buddy, so that we can make an alternative arrangement To respect your Buddy's privacy, and only respond should you be alerted of an emergency

Please use this box to outline anything else you are concerned with

Please check the following

I agree to my contact details being shared with my prospective buddies I agree to make contact with my buddy once I have been allocated to one I agree to respect my buddy and not ask for that buddy to help with daily tasks (such as assistance in the home or shopping for example) I am aware that the buddy allocated to me may not be suitable and will not be offended if they choose someone different I am aware that the buddy I may be allocated to, may not be suitable and agree not to be prejudicial with my reason to be allocated to another I agree to contact my Buddy and Madeira Active, should my circumstances change (leave the island, holiday, health issues, not need a buddy, can't be a buddy or any other reason)

Couples (or for those who don't live alone)

We will be joint buddy's to someone We need a buddy in case something should happen to one of us We live in Madeira full time We live in MAdeira Part time As individuals we spend time apart (visiting family or work away for example)

Please use the box below to add any more information

And finally!

I am interested about 'opting in' for the database (keeping other personal data secured in case of emergency) I am definitely not interested in the database I would like to extend my social circle and attend some Madeira Active events I prefer not to socialise outside my own circle I find it difficult to socialise because I am on my own

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