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The following content is the main page content.
                          
1. Are you joining as an individual or an organisation?
2. Please confirm your name and postcode for us so that we can find you on our database
First Name: *
Surname/Family Name: *
Title: *
Name of Organisation:
Address: *
Postcode: *
Telephone: *
Mobile:
E-mail: *
Clear Organisation
3. How would you Like to be contacted?
Gujarati
Hindi
Polish
Punjabi
Urdu
By email
By telephone
By letter
In person
Large font
Braille
Audio tape
Minicom
Pictorial
By fax
   Other (please specify)
 
4. How you would like to get involved in the LINk
To receive newsletters only
To share issues with other LINk members
To join working groups
To join LINk committees
To campaign and lobby
Active Member
Passive Member
Prospective Member
5. Your Interest
 Health Care
Long Standing Illness
Mental Health
Learning Disability
Physical Disability
Sensory Disability
Substance Misuse
GP Practice
Dental Care
Hospitals
Ambulance
Community Transport
 Social Care
Mobility
Residential Care
Domiciliary Care
Respite Care
Day Services
 Other Areas of Interest
Health, Wellbeing, Fitness
Children
Young People - 16 and over
Older People
Carers
Any other areas of interest not previously mentioned
6. What would you like the LINk to do?
It is essential that the LINk knows about local Health & Social Care issues and priorities. Please use the space below to tell us about your ideas for the work of the LINk. This can be as general or specific as you like
My priorities are:
It is important that the LINk considers this issue because
7. Optional Personal Details
This section asks some personal questions. It also provides very important information for the LINk in order to make sure we reach all sections of the community.

To help us monitor this, we would be grateful if you would fill in the following section. We will keep all information you provide securely.

I would describe my ethnic background as:
White


Black or Black British

Mixed


Other Ethnic Group

  
   
Asian or Asian British



My gender is
Male Female
How old are you?






I would consider myself disabled


My religion is










 
  
8. Your Skills
What kind of expertise would you like the LINk to be aware of? Please tick the relevant box(s) below:
Administration
Financial
Legal
Training
Campaigning
Fundraising
Presentation
Governance
Communication
Health
Information Technology
Research
Community Involvement
Community Knowledge
Project Management
    Other (please specify)
 
Your knowledge of local contacts and networks is very important to the LINk. Please let us know about the networks and organisations that you believe we should make contact with:
9. Data Protection Statement
Information provided on this Membership Form will be held securely on the LINk Database at CVS Community Partnership and will not be passed on to a third party. Under the Data Protection Act 1998, you have the right to access this information. We will only use this information to contact you about LINk activities and monitor equalities within the project. Please click here to indicate your agreement to us using your information in this way.
10. Your agreement to the following is required in order for you to join the LINk
•  My details will be added to Leicestershire LINk's membership database so the LINk can send me information about health and social care services.
•  My level of involvement in the work of Leicestershire LINk is up to me.
•  I agree to the Code of Conduct for LINk members.
•  I will notify Leicestershire LINk as soon as possible if I wish to have my details changed or removed.

Please tick here to indicate your agreement

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