Rotherham Referral Network Registration Form

Please complete the form below and we will get back to you as soon as possible.

Refernet Registration

Organisation details

Organisation name *

Organisation address

Organisation postcode

Organisation website

Organisation email address *

Organisation telephone number

Briefly tell us about your organisation and the support you provide

How would you like to use Refernet?

Make referrals only

Make and receive referrals

Primary Refernet contact

Please nominate one person who will be responsible for your organisation's Refernet account. Additional users can be added later.

Name

Before you join

To use Refernet, organisations must have appropriate arrangements in place to protect client information. Please read the Refernet Protocol prior to submitting your registration request.

Consents

I confirm that our organisation has appropriate policies and procedures covering data protection, client confidentiality and data security.

I confirm that our organisation holds appropriate registration with the Information Commissioner's Office (ICO), where required.

I have read and agree to comply with the Rotherham Referral Network Protocol.

I confirm that I am authorised to submit this application on behalf of the organisation.

Name of person completing this form

Role

If you are human, leave this field blank.

Rotherham Referral Network Registration Form

Organisation details

Primary Refernet contact

Before you join

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