Membership Application Form

First Name

Last Name

Email Address

Telephone

Organisation

Your Position in Organisation

Registered Manager Name

Registered Manager Email Address

Organisation Address Line 1

Organisation Address Line 2

Organisation Address Line 3

City

Postcode

Which council areas do you work in?

Essex County Council

Southend City Council

Thurrock Council

Which health areas do you work in?

Hertfordshire and West Essex

Mid Essex

South Essex

Suffolk and North East Essex

What type of service(s) do you provide?

Area of Specialism

Mental Health

Learning Disabilities

Older People

Young Adult

Adult with Disabilities

Other

How many employees do you have? Please estimate if you do not have exact figures.

Employees within Essex

Employees within Southend

Employees within Thurrock

How many settings providing care do you have? Please estimate if you do not have exact figures.

Number of settings within Essex

Number of settings within Southend

Number of settings within Thurrock

What is your capacity? Please estimate if you do not have exact figures.

Number of Beds (if residential setting)

Number of Domiciliary Staff

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