QRNC. Membership & Monitoring Form






Membership & Monitoring Form - 2010 @ Queens Road Neighbourhood Centre Please complete the membership form front contact details sheet and the monitoring form and return it to us by post. Please also make sure you read the covering letter and the members agreement before signing and returning the forms. Thank you for your support. Your Contact Details Name ................................................................................................. Address............................................................................................. ......................................................................................................... Post Code ........................................................................................ Tel. Number ................................................................................... Email Address (Optional)................................................................................ Membership Agreement Queens Road Neighbourhood Centre (QRNC) has a member’s agreement that we hope you will sign to demonstrate that as a member you agree to abide by, and act in the best interests of, the centre. Please sign in the indicated space below to indicate you have read, understood and will abide by this agreement. Thank you. As a member of QRNC I will always act in the best interests of the centre: Signed…………………………………………………………………… Date……………………………………………………………………… For QRNC office use only Membership number……………………………………………. Date of card issue……………………………………………… Expiry date………………………………………………………… Gender : Please tick here Male ............... Female ........... Age : Please tick here 18yrs to 25 yrs ................................. 25yrs to 35 yrs ................................. 35 yrs to 45 yrs ............................... 45yrs to 55yrs ................................. 55yrs to 65yrs ................................. Over 65 yrs ...................................... Disability – Do you consider yourself to have a disability? Section 1 of the Disability Discrimination Act (1995) defines a person as having a disability if he/she “has a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day to day activities” YES ................ NO ................. If you have answered “YES” to having a disability, how would you describe this? Please tick here Physical disability........................................Learning disability............................. Visual impairment...................................... Mental Health or Distress...................... Hearing impairment or Deaf .................... Long term limiting illness...................... Racial Or Ethnic origin Are you: Please tick here White British................................................................. Irish ................................................................... Other white background (State here) ..................... Black Caribbean ............................................................ African ................................................................ Mixed White & Black Caribbean ................................................ White & Black African .................................................... White & Asian ............................................................... Other mixed background (State here) ............................ Asian Indian....................................................................... Pakistani.................................................................... Bangladeshi............................................................... Other Asian background (State here)............................ Chinese............................................................... Other background (State here)............................ Sexual Orientation How would you define your sexual orientation? Please tick Heterosexual (Straight) ............................................... Gay .......................................................................... Lesbian .................................................................... Bisexual................................................................... Please Return To Centre Manager or Administrator Queens Road Neighbourhood Centre 40-42 Hertford Road Bootle L20 7DH Telephone number : 0151 933 4737
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