Local Action Group (LAG)

Membership Registration Form

You should complete this form if you wish to join your Local Action Group (LAG) in the Derry City & Strabane District Council area. To be eligible you must live or work in the rural area covered by the LAG and be committed to getting actively involved in the development of your LAG and area.

I confirm that:

I live in the LAG area?I work in the LAG area?

SECTION 1: PERSONAL INFORMATION: (Please print clearly and complete in full)

Name:

Address:

Gender /
Female /
Male
Age group:
18-2021-2930-39

40-4950-5960 or older
Ethnicity: How would you describe your ethnic group?
Disability: Do you consider yourself to have a disability?
Under the Disability Discrimination Act 1995 a person is considered to have a disability if he or she has “a physical or mental impairment which has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities” /
Yes /
No
SECTION 2: INTEREST AND SKILLS

Which of the following sectors/categories would you fall under?

(these are the three categories of social partner places on the LAG board)

Category
Community/Voluntary Sector / Farm Diversification
Business/Enterprise

Please indicate your main area(s) of interest in rural development - please tick your top 3 preferences

Areas of Interest
Business and Entrepreneurship / Basic Services in rural areas
Conservation/Heritage / Social Economy
Cooperation / Tourism
Energy / Village Renewal
Environment / Women
Farm Diversification / Young People

SECTION 3: POTENTIAL INTEREST AND INVOLVEMENT

As a LAG member you have an opportunity to participate in other activities, for example, to stand for LAG Board elections or get involved in thematic activities or working groups. Please tick all that apply below:

Become a Director of the LAG Board
(the decision making body of the partnership)
Participate in Sub-Groups or Thematic Working Groups
(such as a working group linkedto one of the funding schemes e.g. Business, Basic Services, Broadband)
Contribute to the development of Co-operation Projects
(projects with other LAGs)
Take part in networking events & activities on behalf of the LAG
Signature: / Date:

Deadline for submission of form is 12 noon on Friday 27th October 2017

By post or hand deliver to – Shonagh Higgenbotham at Derry City & Strabane District Council at either:

Derry Office: 98 Strand Road, Derry, BT48 7NN or Strabane Office: 47 Derry Rd, Strabane, BT82 8DY

Or by email to:

Data Protection: Personal data is gathered in accordance with the Data Protection Act 1998. Your data will be held on a membership database and will be used to engage with you on LAG/Rural Development and Rural Network NI activity. Your data will not be shared with other organisations outside the terms and conditions of the LAG/Rural Development and Rural Network NI. If you do not wish your information to be used for these purposes please contact