Don’t Miss Out - Get Informed

Contact North East Registration Form

If you would like to receive free copies of the Contact regional newsletter and our regular email bulletins, please add your details below.

First Name / Family Name
Please tick:
Mother ☐ Father ☐ Other Carer ☐ Other Relative ☐ Professional ☐
If professional, please add
Job Title ……………………………………………………………………………………
Organisation …………………………………………………………………………......
Address
Telephone Number
Email Address
Name of Child/Children with Additional Needs
Child/Children’s Date of Birth(s)
Child/Children’s Gender / ☐M ☐F (tick or add number if relevant)
Child/Children’s Condition/Disability
If you would like any specific information, please add details here

Please see over

By filling out this registration form, you understand and agree to your details being entered onto the Contact database. Your personal data will be held and used in accordance with the Data Protection Act 1998 and will not be shared with any third parties for commercial use. It will only be used by Contact for the purpose of informing you about news, information and events. We may also contact you from time to time to ask if you would like to participate in our research and consultations. Normally we will contact you by email however we may also contact you in writing or by phone.

We would also like to contact you occasionally, by post or email, about opportunities to support Contact in delivering services and support to families. This could include information about our campaigns and fundraising. We promise that we won’t overwhelm you with lots of information that you don’t want and that you can change what we contact you about at any time.

If you are happy for us to do this please click in the box below:

☐I am happy to be contacted about campaigns and fundraising

You can amend or remove your details or change how we contact you whenever you wish by contacting Contact at

Signed……………………………………………………………………………………………………

Date……………………………………………………………………………………………………

Please return your completed form via email to or send the paper version to Contact, The Dene Centre, Castle Farm Road, Gosforth, Newcastle upon Tyne NE3 1PH

Office use:

To be completed when information is recorded on CONNECT / Date
Connect Contact Record Completed for Adult and Child/Children
ConnectAdvice Record Completed
Information sent to parent/carer (NE Office to send guides or posted information if requested)
Added to email list (NE Office to do)

Electronic Version 9/17