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Membership Form To check if you are eligible for FREE Community Southwark membership, please answer two simple questions. Is your organisation/group not-for-profit? Does your organisation/group work or is based in Southwark or in an adjacent borough to Southwark? If it is a yes to both, please complete this form and return it to Community Southwark. How did you hear about Community Southwark? Organisation name Main contact Job title Your email address Address City Postcode Main telephone number Main email address Website Twitter Facebook Linked in Registered charity Registered company Yes Yes No No Number: Number: What is the annual income of your organisation? No income £100,001 - £500,000 Less than 10,000 £500,001 - £1 million 10,001 - £50,000 £1,000,001 - £10 million £50,001 - £100,000 More than £10 million How many staff does your organisation employ? How many volunteers (including trustees) are involved with your organisation/group Aims of your organisation: Registered charity (no. 1105835) and a company limited by guarantee in England and Wales (no. 5090324). Tell us what the main purpose of your organisation is (please try and keep it to one or two things). Animal welfare Arts & culture Campaigning Community Education & training Faith Fundraising Grant making Other (please specify) Health& social care Housing Information, advice & legal International aid Sport & leisure Sustainability/ environment Support services Transport Now tell us who your main beneficiaries are (again, please try and keep it to one or two groups). Adult Learners Animals Bereaved People Black, Asian, Minority Ethnic & Refugee Groups Carers Children & Families Disabled people Faith Community Forces / Ex-Forces General Public Homeless People People living in poverty LGBT Masons Other (please specify) Men Older People Organisations Patients People with Addictions Prisoners / Ex-Offenders Residents & Tenants Single Issue Groups Survivors of abuse Trafficked People / Sex workers Unemployed People Women Young people Nearly there, just a couple of other things to check. Please tick if your organisation provides services to residents of Southwark Please tick this box if you do not want your organisation’s details shown on the Community Southwark website Please tick this box if you do not wish your organisation’s details to be passed onto a third party for marketing purpose. If you would like to be a Healthwatch Southwark supporter please tick here or visit www.healthwatchsouthwark.co.uk for more details. Declaration I/We agree to abide by Community Southwark’s governing document and membership policy. I/We will support Community Southwark’s and its charitable objects. Signed Date Please return the completed form to: Community Southwark | 1 Addington Square | London | SE5 0HF or email it to [email protected] Registered charity (no. 1105835) and a company limited by guarantee in England and Wales (no. 5090324).