Please fill in and submit this form to register as a member of Wirral LINk.* = required
Title:
Mandatory field First Name:*
Mandatory field Surname:*
Address:
Postcode:
Home Tel:
Mobile:
Email:
How would you like to hear from us? (Please tick all that apply) Post Telephone Email
Are you 18 years of age or over? Yes No
Mandatory field Are you joining as* An Individual Representative of Group / Organisation
If joining as a representative from a group, please provide details of the name of the group / organisation and contact details:
Do you have a preferred method of communication (e.g. Large print, tape, other language)
Do you have any specific needs (e.g. special diet, translator, wheelchair access, lip-speaker, other)
Sectors of Interest: Children & Young People Older People Black & Racial Minority Faith Advice Services Family Services Gender Gay, Lesbian, Bisexual & Transgender Drugs & Alcohol Housing Regeneration & Homelessness Mental Health Physical Health / Disability Health Support & Well Being Carer
Other Interest:
Areas of Interest: Health Social Care Both
Please describe the nature of your work briefly (no more than 20 words please):
Mandatory field Involvement of Membership* Informed Informed & Active Informed / Active / Board
As a LINk that wants to be as inclusive as possible we regularly review the diversity of our membership. We would be grateful if you would answer the optional questions below to help us ensure that we are reaching all sections of the community.
Gender - Male Female
Year of Birth
Marital Status - Married Single Living with Partner
Do you consider yourself to have a disability or learning disability? Yes No
What ethnic group do you class yourself to be? - White - British White - Irish White - Other Mixed - White & Black Caribbean Mixed - White & Black African Mixed - White & Asian Mixed - Other Asian or Asian-British - Indian Asian or Asian-British - Pakistani Asian or Asian-British - Bangladeshi Asian or Asian-British - Other Black or Black-British - Caribean Black or Black-British - African Black or Black-British - Other Chinese Other Ethnic Group Not stated
What is your country of permanent residence if not the UK?
What is your first language?
What is your employment status? - Employed full time / part time Volunteer Retired Unemployed Student
By submitting this registration application form you agree that the Wirral Local Involvement Network (LINk) may store your details on an electronic database and share information with others who may wish to access information about the LINk. If you agree to this, click on 'Join Now!' below.
