Cultural CompanionsSign Up Form Thank you for your interest in Cultural Companions.We hope that you’ll enjoy being part of this new network and that it will provide you with the opportunity to meet new people, get out more and enjoy all that Irish arts & culture has to offer.Completed application forms can be returned by post or email.

If you have any questions or queries, please contact:

Michelle Morrison

Wexford Arts Centre

Cornmarket, Wexford

(Wed &Thursday)

Phone: 053 9123764 ext 3

E-mail:

Web:

PERSONAL DETAILS

Full Name:
Address:
Landline No:
Mobile No:
Email:
Your age range / 55 – 64 ___ 65 - 74 ___ 75+___
How did you hear about
Cultural Companions?
What’s your main reason for wanting to get involved?

PREFERENCES (Tick where appropriate)

Would you prefer... /
  • To meet people of all ages
  • To meet people around my own age

In terms of company, would you prefer... /
  • The company of one other person (1:1)
  • To meet up with a few people (2 - 4 people)
  • To go out and mix with a larger group (10 people approx)
  • Don’t mind either way

In terms of gender, would you prefer... /
  • To meet up with other women like myself
  • To meet up with other men like myself
  • Don’t mind either way/would enjoy the company of both

TRANSPORT

Do you drive / have own transport?
If yes, would you be happy to collect someone from their home if required (within reason)
If no, would you require/need transport to some/all events (i.e. evening time)

HOW OFTEN DO YOU GET A CHANCE TO GO TO SHOWS, FILMS ETC THAT ARE ON?

Almost never Once a year 2-3 times a year MonthlyFortnightlyWeekly or more

______

ARE THERE THINGS THAT MAKE IT DIFFICULT FOR YOU TO HAVE AN ACTIVE SOCIAL LIFE?

Transport issues Confidence issues

Lack of suitable people to go out withLack of information about events

Mobility Issues Just never think about going

Money Issues Out of the habit/out of the loop

Other ______

HOW OFTEN WOULD YOU LIKE TO GO TO SOMETHING?

Once a week____Fortnightly____

Once a month____Every few months____

WHEN WOULD SUIT YOU BEST?

Daytime generally ____

Evenings generally____

Both: Daytime and/or evening____

Weekdays____

Weekends____

Both: Weekdays and/or weekends____

WHAT TYPES OF EVENTS INTEREST YOU? (Tick as many as you like)

Cinema

Live music (i.e. traditional, concerts)

Theatre

Dance

Art galleries

Musical theatre

Poetry Readings

Local amateur dramatics

Opera/classical

Talks & lectures

Festivals

Other

Please specify ______

Do you attend any classes or are you a member of any club (i.e. art class, book club, local choir)

______

UNDERSTANDING YOUR NEEDS:

PLEASE TICK AS APPROPRIATE (you can tick 1, 2 or all 3, depending on your needs)

Bi-Monthly Event Guide / I would like to attend regular organised Cultural Companions events
Network Yourself using the CC Directory / I would like to meet/make contact with people myself (i.e. living around my own area) by contacting other members directly and organising to go to events whenever it suits me

OTHER INFORMATION

Are there any local organisations/groups in your community who you think should be informed about Cultural Companions and/or have you any suggestions for how we could ‘spread the word’ about it?

Do you have any initial questions, queries or concerns about Cultural Companions?

IMPORTANT INFORMATION: PLEASE READ

Your contact details will be held on Wexford Arts Centre database.

Information will not be disclosed to external third parties without your consent.

Wexford Arts Centre may wish to contact you in connection with a variety of programmes or initiatives it is running. If you do not wish your personal data to be used in this way, then please tick this box

The CC Directory is a contact list of Cultural Companions members and is posted out to registeredindividuals ONLY. It provides general information about members and is a useful way of knowing what other Cultural Companions live in your locality. The idea is that you use the directoryto network yourself, make direct contact with other members and perhaps organise to go to local events together, share a taxi etc. The CC Directory contains the following information:

  • Your Name
  • Contact Number (of your choice - either landline or mobile)
  • Area (i.e. Rosslare) you live in - not your specific address

No other personal information is included

If you do not wish for your contact details to be listed in the Cultural Companions Directory then please tick the box