Compassionate Network Application Form

Name of individual, organisation, network or community group making the application *

Contact name *

Telephone number *

Email *

Option A: I would like to join the End of Life Compassionate Network and work on the following areas: * SchoolsWorkplacesPlaces of worshipCare HomesThe artsPeacetime memorial paradeDiversity and reducing inequalitiesHomeless and imprisonedCommunities and neighbourhoodscafes and social spacesGP surgeries

Option B: I support the Compassionate City Charter: A public health approach to end of life care and would consider joining the End of Life Compassionate Network in future *

Date *