Download Membership Form - Community Southwark

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).