Welcome to SomersetIMPACT

Membership Application Form

To apply for membership to Somerset IMPACT...

Please fill in the shaded areas of the following form, including the Membership Fee and Data Protection Act sections below. Please read all the notes, terms and conditions set out here.



		The aims of SOMERSET IMPACT are to... Bring together agencies and people with an interest in children’s disability issues; Promote consultation with parents, and act as a lobby and advocate for services to children with special needs and their families; Provide information on Somerset services and support networks and related topics for children with any special need or disability, and their families.

		MEMBERSHIP OF SOMERSET IMPACT OFFERS... Promotion of your own organisation; Information base on many relevant issues; The opportunity to meet and work with people to improve the overall quality of life available to children who have special needs and their families in Somerset; The opportunity to take part in active and meaningful consultation with statutory agencies on a countywide basis; Free News Updates three times a year.

Contact Name: * (required)

Organisation:

Address: *

:postcode

Telephone number: *

E-mail address:

Interest group /

type of work: *



		MEMBERSHIP FEE £10 per annum for individuals or small organisations £25 per annum for organisations with incomes in excess of £50,000 Parent groups with little or no funds can request free membership (If you are not sure which fee scale applies to you, do please contact us)

Please tick the

appropriate box: *

I wish to:

Pay by Cheque

'I will send you a cheque for the following

amount (above), made payable to SOMERSET IMPACT':

Request free membership

Please contact us for more information



		DATA PROTECTION ACT Somerset Impact’s membership consists of local divisions of large national voluntary organisations, small local voluntary organisations, support groups and individuals who support our beliefs in promoting the interests of children with special needs, informing parents and ensuring their voice is heard in service planning. From time to time members of Somerset Impact request the full membership list to facilitate distribution of information but we need your permission to do this. If you agree for your name to be included, please indicate below:

I am happy for my details on Somerset Impact’s mailing list to be disclosed to other members.

(Please tick)

Name:

Organisation:



		SEND APPLICATION Click on the 'Send Application' button below to send this form to Somerset Impact staff. On receipt of your cheque (of if arrangements have been made for free membership), you will be contacted for confirmation. MEMBERSHIP DURATION: March 2003 - February 2004