Letham4All Membership Form

Question Title

* 1. Personal and contact information

Name

Address

Address 2

City/Town

County

Post Code

Email Address

Phone Number

Question Title

* 2. Which of the following are the main reasons you want to be a member of Letham4All SCIO

Want to improve things in Letham and North Perth City

Further education/training

Use my spare time well

Increase my confidence

Help me into paid work or education

Improve my health

Help learn new skills

Meet new people

Other (please specify)

Question Title

* 3. Equality and diversity information - please select which age category you belong

Under 18

18-24

25-34

35-44

45-54

55-64

65+

Question Title

* 4. Equality and diversity - which of these best describes your ethnic group

White Scottish

White other British

White Irish

White other

Asian Bangladshie

Asian Chinese

Asian Indian

Asian Pakistani

Asian Other

Black African

Black Caribbean

Black other

Mixed background

Not supplied

Other (please specify)

Question Title

* 5. Data protection and declaration - By submitting this information you are giving Letham4All SCIO permission to use it in accordance with the Letham4All SCIO Privacy Policy which can be found on our website , www.Letham4All.org.uk

Date