Membership Application Form 1^st January – 31^st December 2010

Please complete the form below with your subscription of

 £10.00 by cheque made payable to RCN OHNG-SW and return to:Siân Edwards (membership secretary), 36a Gloucester Street, Malmesbury, Wilts, SN16 0AA

Cheques should be made payable to RCN SW OHNG.  Receipt will only be provided if S.A.E. is enclosed.

Date: _____________________________       RCN No:  __________________________

Full name: __________________________________________________________________

Mailing Address:_________________________________________________________________

_______________________________________Post Code:  _________________

E-mail address:__________________________________________________________

To reduce cost correspondence will only be sent by post if specifically requested.                            

Telephone (home): ________________________   Telephone (work):  ______________

Place of Work __________________________  Job Title:________________________

Nature of business/employment: ___________________________________________

Qualification (circle those applicable): RGN/OH Certificate/Diploma/Degree/Other

Please give further details____________________________________________

Would you be interested in volunteering to help or join the committee?  Yes/No

Would you be interested in offering clinical support to a colleague?       Yes/No 

Do you want to be included in a membership directory for distribution to the group for networking purposes?                                                                                       Yes/No

Please circle your preferred area for study days:   Cornwall/Plymouth/Exeter/Taunton/Other

Please give details:__________________________________________________

Data Protection Act   Please note that by submitting this form you are granting us your permission to hold a record of your details.  This data will be used for the sole purpose of the RCN OHNG-SW and it will not be shared with any other organisation.