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* 1. Name of organisation / group

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* 2. Contact name

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* 3. Position in organisation / group

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* 4. Address of organisation / group

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* 5. Postcode

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* 6. Telephone

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* 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.

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* 8. Website

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

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

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* 11. Is your group based in Ealing?

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* 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

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

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

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

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

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* 18. If you would like to know more about how we deal with your data and would like to know how to contact us regarding this and any other personal data issue please follow this link to our website and Privacy Statement.   Click Here

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