Joining form

Title(required) Mr

Mrs

Miss

Ms

I do not wish to use a title

First name(required)

Surname(required)

Date of Birth(required)

Phone Number(required)

Mobile Number

Address – Street and number(required)

Address – Town(required)

Address – County(required)

Address – Postcode(required)

Address – Borough Elmbridge

Epsom & Ewell

Guildford

Mole Valley

Reigate & Banstead

Runnymede

Spelthorne

Surrey Heath

Tandridge

Waverley

Woking

Outside Surrey

I don't know

Email

Ethnicity White (English/Welsh/Scottish/Northern Irish/British)

White (Irish)

White (Gypsy or Irish Traveller)

White (Any other White background)

Mixed/Multiple ethnic groups (White and Black Caribbean)

Mixed/Multiple ethnic groups (White and Black African)

Mixed/Multiple ethnic groups (White and Asian)

Mixed/Multiple ethnic groups (Any other)

Asian/Asian British (Indian)

Asian/Asian British (Pakistani)

Asian/Asian British (Bangladeshi)

Asian/Asian British (Chinese)

Asian/Asian British (Any other)

Black/ African/Caribbean/Black British (African)

Black/ African/Caribbean/Black British (Caribbean)

Black/ African/Caribbean/Black British (Any other)

Other ethnic group (Arab)

Other ethnic group

Skip this question

Gender Female

Male

Non-binary

Other

Wish not to disclose

Membership type I am a disabled person (full member)

I am unpaid family member / carer (associate)

I am a professional

I have a (please tick as appropriate) Learning disability

Physical disability

Neurological Impairment (ABI)

Hearing Impairment

Visual Impairment

Mental Illness / ill health

Long term health condition

Other (please specify)

I am interested in: Transport

Equipment

Technology

Projects

Healthcare

Social Care

Consultations

Social Activities

Music Group

Craft Club

Get Active Group

Special Interest Groups Long Term Neurological Conditions group

Hard of Hearing Forum

Surrey Vision Action Group

Community Equipment Group

Disability Empowerment Network Surrey (DENS) North DENS

Mid DENS

South West DENS

East DENS

Other groups Talk about Tech Group

Virtual Cafe

Young Adults group

Virtual Social Activities

Promotional events

Training and awareness events

Independent Mental Health Network (IMHN) – this is for anyone with any experience of mental ill health (you do not need to have experienced mental health services)

FoCUS – this is for people who use Surrey and Borders Parntership NHS Foundation Trust services and their carers

Other (please specify)

Information requested

Communication preference

Preferred newsletter format:

Please DO NOT contact me (Please note that if you tick this box you will be registered as a member with us, but we will NOT be able to contact you with information relating to your areas of interest)

IMPORTANT INFORMATION:In accordance with the Data Protection Act 2018, all information provided on this form and in any further dealings with Surrey Coalition will be treated as confidential and will not be disclosed to any third party without express consent from you. However, it is important that you understand that on occasions organisations are obliged to share certain information, for example if an individual is at risk to self or others, and we may be obliged to share your information with Surrey Multi Agency Safeguarding team; Vulnerable Adults team; Child Protection team; other staff; Service's Regulator(s) and other agencies. Should this need arise we will make every effort to discuss this with you prior to any information being shared.I confirm I have read, understood and agreed with the statement above and I give permission for Surrey Coalition of Disabled People to store and use my personal data with the intention of coordinating my involvement in the activities of the organisation and to send me a regular newsletter and general updates that might be of interest to me. I understand that in the unlikely event of Surrey Coalition of Disabled People going into liquidation, I may have to pay £1.00 towards its liabilities. Choose one(required) I agree

I do not agree

Surrey Coalition of Disabled People

Joining form

Section 1. Member contact information

Section 2. Membership type and information

Section 3. Interests and groups

SECTION 4: Communication & Mailing Preferences

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