Joining form

We’re delighted that you’d like to join us and we look forward to welcoming you.

By completing this form, you can join any (or all!) of the following areas of our work:

Become a member of Surrey Coalition of Disabled People
Register your interest in our Tech to Community Connect service
Register your interest in our Independent Mental Health Network.

Please complete the sections for the particular area(s) that you are interested in.

Section 1. Information about you

Title(required) Mr

Mrs

Miss

Forename(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(required)

Email(required)

Gender

Ethnicity

Preferred means of contact

Other, please specify

Disability

I am a Disabled person

I have a: Learning disability

Physical disability

Neurological Impairment/ ABI

Hearing Impairment

Visual Impairment

Mental Illness / ill health

Long term health condition

Other, please specify

I am unpaid family member / carer

I care for someone with a / am interested in (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 a professional and interested in (Tick all that apply)

Other, please specify

Section 2: Which Networks would you like to join? Please tick all that apply:

Surrey Coalition of Disabled people (please also complete sections 3 and 6)

Full Member (I am a Disabled person)

Associate member (Carer or unpaid family member)

Professional

Tech to Community Connect

This is a project that works to reduce digital exclusion by providing devices , digital literacy, training and support I'd like Tech To Community Connect to contact me (Please also complete sections 4 and 6)

Independent Mental Health Network (IMHN)

I'd like Independent Mental Health Network to contact me (please also complete sections 4 and 6)

Section 3 Membership of Surrey Coalition of Disabled People

Please only complete this section if you would like to join the Coalition.

As a Coalition member, you will become a part of the Disability Empowerment Network in your area (North Surrey, Mid Surrey, South West Surrey or East Surrey). Attending the meetings is not compulsory, but we would love to hear your views!

Please tick those you wish to receive information about

Groups you would like to join (please tick those you’d like to receive information about):

Special Interest Groups Long Term Neurological Conditions group

Hard of Hearing Forum

Surrey Vision Action Group

Community Equipment Group

Direct payments group

Patient transport group

Let's Hear Surrey

Disability Empowerment Network Surrey (DENS) North DENS

Mid DENS

South West DENS

East DENS

Other groups Virtual Cafe

Young Adults group

Virtual Social Activities (Book group, craft group, weekly quiz)

Virtual trips

Training and awareness events

Promotional events

Other, please specify

Information you would like to receive

Coalition Newsletter

Coalition weekly update

Information about my interests

Information about volunteering for the coalition

If you would like to receive the quarterly Coalition Newsletter, what format would you like to receive it in?

Section 4: Membership of Tech to Community Connect

Please only complete this section if you would like to use the Tech to Community Connect service.

Do you have a computer, a smart phone or a tablet?(required)

Do you have Wi-Fi connection where you live?(required)

Do you receive any means-tested benefit (that would entitle you to a cheaper broadband plan from BT)?(required)

Do you live on your own?(required)

Please provide a name and phone number for an emergency contact (e.g. a family member, carer or good friend):(required)

Can we visit you at home?(required)

Are you an unpaid family carer?(required)

Section 5: Membership of the Independent Mental Health Network

Please only complete this section if you would like to join the Independent Mental Health Network.

Groups that you would like to join in addition to the main Independent Mental Health Network group (please tick all that apply): North West Surrey Stakeholder Group

Mid and East Surrey Stakeholder Group

Young Adult Stakeholder Group

Mental Health and Black, Asian and Minority Ethnic Stakeholder Group (this group is run in collaboration with Surrey Minority Ethnic Forum)

Focus groups/project groups (please tick all that apply): Serious Mental Illness (SMI)

Crisis Mental Health Service

Technology and Mental Health

Adult Social Care Services

Physical Health Services and Support

Community Mental Health Services

Young Adults and Transition

Other, please specify

Other ways to be involved North West Surrey Stakeholder Group

Mid and East Surrey Stakeholder Group

Young Adult Stakeholder Group

What is your sexuality?

Section 6: Consent and Data Protection

In order to join the networks you have chosen, we need your permission to keep and use the information you give us about yourself. Please read and complete this section.

When you sign (or submit electronically) this form, you are giving your consent to become a member of the networks run by Surrey Coalition of Disabled People which you have ticked on this form. Surrey Coalition will store and process the information provided on this form and any other information you might subsequently provide to administer your membership. We are committed to keeping information about you secure and confidential. You can find out more about how we do this in our Privacy Policy.

For members of Surrey Coalition of Disabled People:

If you have chosen to become a member of Surrey Coalition of Disabled People, please note that your liability is limited to a maximum of £1. This means that in the unlikely event of Surrey Coalition of Disabled People going into liquidation, the maximum that you may have to pay towards the organisation’s liabilities is £1 only.

For members of Tech to Community Connect:

I understand that Surrey Coalition of Disabled People will share limited details such as my telephone number and address with Surrey County Council to co-ordinate Tech Angel support visits with me.

I confirm I have read, understood and agree with the statements above and I consent for Surrey Coalition of Disabled People to store and use my personal data to administer my membership of the networks I have chosen, including sending me information that might be of interest to me.

Sign by typing in your name below(required)

Date(required)

Surrey Coalition of Disabled People

Joining form

Section 1. Information about you

Preferred means of contact

Disability

Section 2: Which Networks would you like to join? Please tick all that apply:

Surrey Coalition of Disabled people (please also complete sections 3 and 6)

Tech to Community Connect

Independent Mental Health Network (IMHN)

Section 3 Membership of Surrey Coalition of Disabled People

Information you would like to receive

If you would like to receive the quarterly Coalition Newsletter, what format would you like to receive it in?

Section 4: Membership of Tech to Community Connect

Section 5: Membership of the Independent Mental Health Network

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