Hear Us Membership Application Form

NOTE
DOES IT COST ANYTHING? No. Membership is totally free. WHAT DO I GET? You get up to date information from our quarterly newsletters which keeps you informed on local services.You also get access to a range of information about mental health matters. LIKE TO JOIN? Complete the form below and submit it or phone us on 020 8653 6045

Part 1

Membership Criteria

A Resident in the London Borough of Croydon

B and/or Have a recognisable interest in the Mental Health Service User issues in Croydon

C and/or Have had an emotional, psychological problems or some form of mental illness

Your Name:

Address:

Your Email:

Your Telephone:

Date of Birth:

Your Age:

Gender

Ethnicity:

Membership Status (Full Membership Status see Criteria A,B & C Above)

Comment or Requests:

Declaration
I declare that the information I have given on this form is correct and complete. Please enrol me as a member of Hear Us and I agree to the group's rules.

Your name and address will be held in complete confidence and will only be used by Hear Us for sending out newsletters, invitations to meetings, information regarding the mental health services in Croydon, related matter and we will not pass on your details on to anyone else.

We also use the information for equal opportunity monitoring purposes

I want to become a member of Hear Us

Part 2	Submit Your Application
	Or you can write to us at: Hear Us, Orchard House, 15a Purley Road, South Croydon, CR2 6EZ Or download the application form and post it to the above address Or if you have any questions or queries you can e-mail us at : hear.us@hear-us.org Or you can telephone us on 020 8681 6888