Gloucestershire LINk Registration Form

Gloucestershire Local Involvement Network (LINk)

Please complete the following form - fields marked with * are a mandatory requirement.
View the guidance notes for this form.

Membership Type

Preferred Membership Type:*
Individual MembershipCommunity Group or Ogranisation Membership

Preferred Level of Engagement:*
I wish to become an Active MemberI wish to become a Participant

Contact Details

Title:*

Full Name:*

Address 1:*

Address 2:

Town/City:*

County:

Post Code:*

Email:

Telephone:

Fax Number:

Mobile Number: **

** We need your permission to be able to text you even if we already have your mobile number. By giving us your mobile number you are agreeing to receive information by text message and understand that the information given will be held and used in accordance with the Data Protection Act 1998 and that permission continues to be granted until confirmed in writing that it is withdrawn.

What are you interested in?

Please tick all the areas you are interested in (you can tick more than one box): Health ServicesDentistryMental Health
Social Care ServicesEquality and DiversityOlder People's Services
Ambulance ServicesGP ServicesPharmacy
Care HomesHearing ImpairmentPhysical Disabilities
CarersHospitalsPregnancy/Maternity Services
Children and Young PeopleLearning DisabilitiesVisual Impairment

How can we help you take part in the link?

Please tick any special requirements you have (you can tick more than one box): None
Hearing Requirements
Wheelchair Access
Language Translation
Reading Formats
Replacement carer or childcare for a person I care for
Someone to come to meetings and events with me in a caring capacity
Please give details:

Agreement

Signature Type:*
I can confirm that the information given in this form is true and if required I have the community group or organisation’s Chief Executive’s permission. IndividualRepresentative of Group/Organisation

Approximate number of people/members in your community group/organisatiion:

Required for representatives only

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Please make sure all fields marked with * are completed

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