Membership Registration Form

Please use BLOCK CAPITALS and BLACK INK to complete this form
APPLICANT INFORMATION
Title: / Forename: / Surname:
Where do you work or study? Please tick the relevant box(es)
Professional Category (please select one):
Community and Third sector
Education Staff- please define: College/UniversityPrimary Secondary Private
Student- please define: College/University Secondary Private
Government Department - please state your department below
Local Authority- please state yourdepartment below
NHS - please state which organisation below
Private sector(non-education)
Volunteer(unpaid)
Job / Course Title:
Department:
Organisation/School/NHS Body:
Address:
Postcode:
Landline no.: Mobile no.:
E-mail address:
HOME ADDRESS (Students only)
Home address*:
Postcode:
E-mail address*:
Home contact tel. no(s):

Please Turn Over

AREAS OF INTEREST
Please help us to provide the right service to support you in your work by indicating your areas of interest below*
Health Protection / Workplace Health / Older Adults (65+)
Mental Health / Minority Communities / Parenting
Healthy Eating / Disabilities / Men's Health
Physical Activity / Preschool (0-4) / Women's Health
Sexual Health / Primary school age (4-11) / Long Term Conditions
Substance Use / Secondary school age (11-18) / Training and development
Education / PSHE / Adults (18+) / Public Health Courses
PUBLIC HEALTH RESOURCE CENTRE (PHRC) REGULATIONS
Please take a couple of minutes to read through the PHRC regulations (separate sheet). If there is anything that you are unsure of, or do not understand, please ask a member of staff for clarification.
I confirm that I have read and agree to the PHRC regulations
Signature:Date:
(If filling in electronically, please type full name)
PHRC NEWSLETTER
If you would like to receive ouremail newsletter, which includes information on training events, seminars, new resources, public health news, and information on our local and national campaigns, please tick this box
HOW DID YOU FIND US?
We are always interested to hear how our customers find out about us. Please take a moment to let us know how you heard about the PHRC.

*You will only be contacted at your home address should you have overdue loans and we are unable to contact you via your place of study.

Please return your completed membership form to: -

Staff Use Only:
Library card no:
Date card issued: / WF
Staff initials: / SS

Public Health Resource Centre

Technorth, 9 Harrogate Road, Chapel Allerton

Leeds, LS7 3NB

Tel: 0113 37 86200

Fax: 0113 33 67115

E-mail: