* 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
BMER
Children
Dispute
Education
Environmental sustainability
Families
Health & Wellbeing
Learning Disability
Legal Advice
LGBT
Marriage / Civil
Men
Mental Health
Older People
Partnership
Physical Disability
Religion or Belief
Resolution / Mediation
Sport
Training
Women (inc. pregnancy / maternity)
Youth
Other (Please specify)
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