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Membership Application Form 1st January – 31st 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), 12 Kingswall Malmesbury Wiltshire SN16 9BJ.

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:__________________________________________________

Ethnic background

This information is required to monitor membership trends and complies with RCN requirements. Which of these ethnic groups best describes yourself? Tick one numbered box only.

White

British

01

Irish

02

Any other white background

03

 

Black or black British

African

04

Caribbean

05

Any other black background

06

 

Asian or Asian British

Indian

07

Pakistani

08

Bangladeshi

09

Any other Asian background

10

Mixed

White and Asian

11

White and black Caribbean

12

White and black African

13

Any other mixed background

14

Chinese

 

15

 

Any other ethnic group

 

16

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

 


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