* 1. Name of organisation / group

* 2. Contact name

* 3. Position in organisation / group

* 4. Address of organisation / group

* 5. Postcode

* 6. Telephone

* 7. Email

Please note that email is our main method of communication with the network. We encourage you to provide a contact email address if at all possible.

* 8. Website

* 9. Brief description of what your group/organisation does (max 100 words)

* 10. Legal status of organisation/group
(tick all that apply)

* 11. Is your group based in Ealing?

* 12. If you answered no to Qu 11, does your group work in Ealing?

You must either be based in Ealing or work with services users in Ealing to be a member of Ealing Community Network

* 13. In which of the areas of Ealing are you operating/based?

* 14. How many paid staff members does your organisation have?
(1 full-time member is the equivalent of 35hrs)

* 15. Select up to five "work areas" from the options below, marked 1 to 5 (1 being your highest priority), which your group/organisation is most involved with.

  1 2 3 4 5
Animal Welfare
Arts & culture
Environmental sustainability
Health & Wellbeing
Learning Disability
Legal Advice
Marriage / Civil
Mental Health
Older People
Physical Disability
Religion or Belief
Resolution / Mediation
Women (inc. pregnancy / maternity)
Other (Please specify)

* 16. Are you interested in being part of these Ealing forums run by ECN?
Please tick those that apply.

* 17. Please indicate which eNewsletters  you would like to receive  to the email addresses you have provided.
Please tick all that apply.