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?