Membership form

Title*

Name*

First Last

Address*

Street address Address line 2 Town County Postcode

Home phone

Mobile

Email

We will communicate with you by email, however, if you would like to be contacted in a different way, please let us know.

The information you supply will only be used to contact you about the trust, membership or other related issues. The information will remain confidential and will be held in accordance with the Data Protection Act.

Do you need any communication support?

Hold the control key to select more than one.

Other (please tell us what support you need)

Do you need written information in another format?

Hold the control key to select more than one.

Other (please tell us what support you need)

Date of birth*

Gender*

Male
Female
Other
Prefer not to say

If other, please specify

Do you have a disability or long-term health condition?

Yes
No
Prefer not to say

If you answered yes, would you be willing to share what your condition is?

How would you like to be involved?*

Receive information from us about our services and our charity, i care
Receive invitations to events or working groups
Respond to surveys or comment on leaflets
Receive information about employment opportunities
Become a volunteer

What is your ethnicity?

Other, please describe

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Services

Pages

Leaflets

Membership form

Your information