Membership of the Independent Mental Health Network

Please only complete this section if you would like to join the Independent Mental Health Network. Please note by completing this information, you’ll be added to the Independent Mental Health Network database

Lived In Payment Form Easy Read Version

About You

Your name(Required)

Your email address(Required)

Phone Number(Required)

Co-production Activity

Name of Activity(Required)

How many hours did you complete?(Required)

How would you like to be paid?

How would you like to be paid?(Required)

Bank

Vouchers

If being paid into your bank, please provide your bank sort code and account number(Required)

If being paid by vouchers, where would you like your vouchers for?

Agreement and signature

Data Protection(Required)

I understand that my information will be held in line with my rights under the General Data Protection Regulations (GDPR). I consent to Surrey Coalition of Disabled People storing and processing my personal information in order to manage and communicate with me regarding my application. For more information, please review our Privacy policy https://surreycoalition.org.uk/privacy-policy/

Signature

Please type your name in this box

Now please click on the button to submit your form.