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Joining form

Name(required)

Address(required)

Post code

Mobile

Telephone(required)

Email

Date of birth(required)

I want to join as (please pick one):(required)

I am interested in: Learning Disability

Physical Disability

Visual impairment

Hearing Impairment

Mental Health

Older Person's issues

Other (please state)

Other

I would like to receive audio versions of information (when available)

The 12 Basic Needs/Rights: Disabled people have agreed 12 basic things they need to fully take part in society. Please tick up to 3 boxes which you are most interested in.

Full access to the Environment (towns, countryside & buildings)

An accessible Transport system

Technical aids and equipment

Accessible/adapted housing

Personal Assistance and support

Inclusive Education and Training

An adequate Income

Equal opportunities for Employment

Appropriate and accessible Information

Advocacy (towards self-advocacy)

Counselling

Appropriate and Accessible Health Care

All personal information supplied on this registration form will be treated in accordance with the Data Protection Act and will not be shared with other parties unless we have received your permission to do so or unless it is absolutely necessary.

Surrey Coalition of Disabled People

Joining form

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