Join the LINk
Your contact details
Please enter your contact details below. Membership is free and entitles you to receive our monthly newsletter.
Title:
Title:
First Name:
First Name:
Last Name:
Last Name:
Address1:
Address1:
Address2:
Address2:
Address3:
Address3:
Post Code:
Post Code:
Telephone No (Landline):
Telephone No (Landline):
Telephone No (Mobile):
Telephone No (Mobile):
Email Address:
Email Address:
Do you have any special needs in regards to contact? (please detail):
Do you have any special needs in regards to contact? (please detail):
Where did you hear about the LINk?:
Where did you hear about the LINk?:
Are you joining as an individual or as a representative of an organisation?:
Are you joining as an individual or as a representative of an organisation?:
Organisation
Individual
If you ticked organisation please tell us:
The name of your organisation:
The name of your organisation:
The geographical area your organisation covers:
The geographical area your organisation covers:
Your position in the organisation:
Your position in the organisation:
Purpose of the organisation:
Purpose of the organisation:
Special Interests:
Special Interests:
Ambulance and transport
Hospital and specialist care
Long term and continuing care
Mental Health
Community based services
Public Health
Social care
Other (please specify)
Are you interested in taking a more active role?
We will contact you to discuss the different ways you can get involved:
Are you interested in taking a more active role? We will contact you to discuss the different ways you can get involved:
Yes, I would like to become actively involved in the LINk
Your age group:
Your age group:
Under 18
18-25
26-44
45-64
65 and over
Gender:
Gender:
Male
Female
Transgender
Ethnic Group:
Ethnic Group:
White British
White Irish
Any other White background
Black or Black British - Caribbean
Black or Black British - African
Any other Black background
Asian or Asian background - Indian
Asian or Asian background - Pakistani
Asian or Asian background - Bangladeshi
Any other Asian background
Chinese
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any other mixed background
Gypsy Roma Traveller
Traveller of Irish descent
Any other
Prefer not to say
Disability, or long term illness:
Disability, or long term illness:
I have a disability, or long term illness that limits my ability to carry out normal day-to-day activities.
Sexual orientation:
Sexual orientation:
I am Lesbian, Gay or Bisexual
I am Heterosexual
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