Membership Registration Form for Organisations and Groups

Thank you for taking the time to register your interest in Healthwatch. By completing this form you are asking us to keep you informed about our activities.

Eligibility to join Healthwatch

Any voluntary,community or not for profit organisation or group who can demonstrate charitable or social objectives can join Healthwatch. You do not need to have charitable status or be a constituted group to be a member. To ensure Healthwatch remains independent, statutory local authority and NHS organisations involved in commissioning or providing health and social care services are ineligible for membership.

Contact details:

Name
Organisation/Group
Position
Address
Postcode / Telephone
Mobile / Email

Group/organisation type:

Voluntary CommunityService User Group

Charity Other  please state______

Please tell us about your particular areas of interest and/or expertise in health and social care locally

How did you hear about Healthwatch?

Word of mouthLeaflet/Poster in local Venue

Local PressSearch Engine

Local Event/MeetingSocial Media 

Through another organisation please state if known______

Other  please state if known______

Can you help us share information about Healthwatch with your own networks and contacts? Yes  No  Don’t know 

If we send you information about Healthwatch can this be circulated to your networks via?

Newslettere-bulletinWebsite

FacebookTwitterMail shot

Special format e.g. Braille, Audio please state ______

We want to make sure that Healthwatch is fully representative. By answering the following questions you help us to understand how well we are representing your community.

In which areas does your organisation/group work (Please tick all that apply)

MiddlesbroughRedcar and Cleveland

Stockton-on-TeesSunderland

All of these 

Does your organisation represent any hard to reach communities or those defined by the Disability Discrimination Act (DDA) as disabled*?

(*Someone who has a physical or mental impairment that has a substantial and long-term adverse effect on their ability to carry out normal day to day activities)

Yes No Don’t know 

If yes, pleasetick which communities you represent:

People with Sensory impairmentsPeople with Physical impairments

People with Mental Health IssuesPeople with Learning Disability

CarersOffenders

TravellersBlack and Minority Ethnic (BME)

Lesbian Gay Bisexual & TransgenderChildren and Young People

Older People Armed Forces

Other please state ______

Approximately how many members do you have?  Not known

Do you collect/hold Equality Data about the members of your group or organisation?

Yes No Don’t know 

The information on this form will be stored and processed using a computerised database for the purposes of administering Healthwatch Redcar and Cleveland, run by the Pioneering Care Partnership (PCP), Carers Way, NewtonAycliffe, DL5 4SF. We may contact you in the future to check the accuracy of this information. However, during this period you are reminded that PCP can only keep information about you up to date if you inform us of any changes.

Confidentiality Disclaimer

PCP will treat the information you give confidentially, under the principles of The Data Protection Act 1998 and The Freedom of Information Act 2000. We will share information with our external funders and evaluators only where necessary for monitoring and evaluation purposes. We operate an ‘open file’ policy should you wish to view the personal information the organisation holds please speak to a member of staff.

Please sign below to say that you have read and understood this statement, and agree to PCP using the information you have given on this form.

I have understood and agree to the above confidentiality disclaimer:

Signed: ______Date: ______

If an email address has been provided, we will assume that this is the method via which you want to receive updates.

Please return this form to:

Freepost RTCZ-YTAY-RYYA

Healthwatch, Catalyst House, 27 Yarm Road, TS18 3NJ