Fareham and Gosport 

Voluntary Sector Health Forum

 Community Action Fareham Main Page    Gosport Voluntary Action Main Page

 

Application for Forum Membership by Voluntary Organisations

Please either complete the form below or download the Word version  or  pdf version  then post or email

Organisation
Contact name
Contact address
Contact email
Contact Tele no        Mobile
Contact role in organisation
Description of organisationís work

(This is so that Forum members will understand the work - the description for a public database may be the same or different.)

Web address
  The 3 questions below are to estimate the number of people involved, the support and total numbers. Please give a figure if you have one; don't spend lots of time researching. Thanks.
How many of your members have the long term condition that your group supports?
What is the total number of members your group has? (might include family and supporters)
Do you have an estimate of the number of people in F&G affected by the condition that your group supports? (write a number, percentage, description or whatever may be helpful)
Categories of interest Long-term medical   Disability   Carers
Other (please ensure description above is good)
Do you have an entry in Who Cares directory of health & care support groups? Already have                 Would like information
Does your group already work to a quality standard? Yes   Currently work to

No     Would like information about how this may be helpful.

   
Main Representative As contact given above
Name
Tele nos
(include a mobile number to get text alerts)
       Mobile 
Email address
Deputy Representative         Name
Tele nos        Mobile
Email address
I agree for this information to be available to other forum members for communication and network purposes. Yes    No
I declare that this membership and representation was agreed at the committee meeting held on (please use  dd/mm/yyyy  format)
Name    Role