Download - UiD - Member Registration Form

Transcript
  • How did you hear about the Unity in Diversity Group?

    Personal Details

    Equal Opportunities

    Surname:* Title:

    Forename/s:*

    Home Address:*

    Postcode:

    NI Number:*

    Contact Number:*

    Gender:*(please tick)

    (please tick)

    Disability:

    Date of Birth:* DD/MM/YY

    (Questions marked * are required)

    Female Rathernot say

    NoYes Rathernot say

    Male

    Yes/No

    The United Reformed Church39 Convent StreetSwansea - SA1 2BX

    Contact: [email protected]

    Member Registration Form

    Email:

    Are you getting any money from the Government?

    (please tick)

    Are you: community member asylum seeker refugee

  • How would you describe yourself?Choose ONE section from A to E, and then tick the appropriate box

    Declaration:

    When you sign this form you agree that we can share your information with The Big Lottery, which provides money for our activities. Well keep your informaton safe in line with the Data Protection Act 1998.

    Prefer not to say

    BritishEnglishIrishScottishWelshAny other White background, please write in box

    Asian or Asian British

    Black or Black British

    Chinese or other ethnic group

    Mixed Heritage

    White

    White and AsianWhite and Black AfricanWhite and Black CaribbeanAny other Mixed background, please write in box

    ChineseAny other, please write in box

    AfricanCaribbeanAny other Black background, please write in box

    A

    B

    C

    D

    E

    F

    BangladeshiIndianPakistaniAny other Asian background, please write in box

    Participant Signature:* Date:* DD/MM/YY

    Date:* DD/MM/YYStaff Signature:*

    Staff Use Only