Membership Form

Your Name (required)

Your Job Title

Your Organisation

Address

Post Code

Telephone

Mobile phone

Email (required)

Your Primary Area of Work

Please indicate your primary area of work
AdultsChildrenGeneric

Your Work Activities

What best describes what you do?
PractitionerFrontline managementPolicy/PlanningOperational managementPerformanceStrategic ManagementCommissioning/ContractingInspectionTeaching or TrainingResearch/Evaluation

Work Involvement

With which of the following are you involved?
Early yearsChildren in NeedChildren's CentresOlder PeopleSchools/Extended SchoolsMental HealthYouth ServicesLearning DisabilitiesLooked-after ChildrenPhysical DisabilitiesSensory ImpairmentSafeguarding ChildrenHousingResidential CareCommunity Based CareBlack/Minority Ethnic Service UsersCriminal Justice SystemSubstance Abuse

Your Workplace

Your workplace (Tick more than one if your place of work has merged, e.g. social services and housing)
Local Authority - adultsLocal Authority - childrenLocal Authority - otherVoluntary SectorPrimary Care TrustAcute TrustIndependent SectorCentral Government/National/Regional AgencyFurther/Higher Education

Type of membership

New Multiple MembershipNumber of members in new Multiple Membership, excluding main contact.Join existing Multiple Membership (see list of current member organisations)Individual MembershipStudent or Unwaged

Data Protection

As a member of SSRG, your contact details are kept in our Membership Database for the purposes of printing a mailing list for sending out newsletters, information and details of events. Under the Data Protection Act 2000, we are required to obtain permission for the data to be held for this purpose. Please see our Data Protection Statement for more details.tick here

Basic contact details and information about interests is available to other SSRG members, in the Members Area of this Web site. If you do not wish your details and membership interests to be shared in this way, please tick this box. Tick here

Year of Birth

Year of joining SSRG (if known)

Gender
MaleFemaleTransgenderPrefer not to answer

Disability
Do you consider yourself to have any long standing illness or disability? (Long standing means anything that has troubled you over a period of time or is likely to affect you over a period of time)
YesNo

Ethnicity

White
BritishIrishAny other white background
Mixed
White and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed background
Black or Black British
CaribbeanAfricanAny other black background
Asian or Asian British
IndianPakistaniBangladeshiAny other Asian background
Other Ethnic Groups
ChineseAny other ethnic group
Prefer not to answer
Prefer not to answer

Sexuality
BisexualGayHeterosexualLesbianTransgenderUnsurePrefer not to answer

Any message for us?