Membership Application

Thank you for your interest in becoming a SCIL member . Membership is FREE and by joining you will be part of a local user-led organisation supporting independent living and promoting choice, control and inclusion for disabled people. We will send you regular news updates and our quarterly newsletter keeping you informed about disability issues and what’s happening locally and nationally. You can also choose to be contacted for consultations so that you can be involved and have your say about issues affecting local disabled people.

Please note; if you wish to apply as an individual and as an organisation please complete 2 separate applications.

1. Your Details:

Please give or update your details.

Name: *

Address: *

If you are registering as an organisation please submit the address of the organisation, not your own.

Postcode: *

Contact Number: *

Email: *

Name of organisation:
(where applicable)

Position in organisation:

Website Address:
(for organisations)

Gender: Male Female Transgender

2. About you:

Please √ all those that apply to you.

I am a disabled person.

I am a disabled person

I am a non-disabled person

I am a parent carer of a disabled child

I am a carer for an adult

3. About your membership

Please read SCIL's membership terms before making your decision.

I represent an organisation

I am applying to be: * A full member An Associate member

I have read and agree to SCIL's membership terms: *

4. Areas of interest

Would you like to be involved in SCIL Focus Groups? Yes No

Please √ areas of interest and we will contact you.

Education and Training

Employment

Health and Social Care

Hate Crime

Self-Directed Support

Disabled People’s Rights

Physical Environment

Transport

Other; please specify:

5. Receiving information.

How would you prefer to receive information from us? (Including newsletter): In regular print In large print In plain text format (no pictures) In Braille On audio tape By email

Other format ? Please specify:

Equalities Monitoring

The following questions are voluntary; you do not have to answer them if you do not wish to. But we would appreciate your help in completing these equal opportunities monitoring questions very much! This information will help us to plan and develop services to meet the needs of as many people as possible. It also shows that we are being inclusive.

Impairment/Disability

The Disability Discrimination Act 1995 defines you as disabled if you have a physical , sensory or mental impairment that has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities. SCIL supports a self-defining definition of disability and believes you are disabled if you consider yourself to be disabled.

If you consider yourself to be disabled please can you give us more information?

Please √ all that apply:

Blind or partially sighted

Learning difficulties

Deaf or hearing impairment

Mental health service user or survivor

Long-term health condition

Wheelchair user

Mobility Impairment (not wheelchair user)

I would rather not say

Other; please specify:

Racial and Cultural Origins

Please √ the boxes which best describes your racial, cultural or ethnic origins.

White: British Irish Other

Mixed / Dual Heritage: White and Black Caribbean White and Asian White and Black African Other

Asian or Asian British: Indian Pakistani Bangladeshi Other

Black or Black British: Caribbean Somali Other

Chinese Any Chinese background Other

Other ethnic group: Yemeni Other Arabic

If you have selected other, please specify:

I would rather not say.

Declaration:

“I apply to be a member of Sheffield Centre for Independent Living, a company limited by guarantee number 4639160 and a registered charity Number 1112712, and agree to be bound by its Memorandum and Articles of Association and any rules made under these. I support the aims of SCIL and I understand the conditions of membership.”

If you need any help filling in this form, or require it in a different format, we’re happy to help!

Call us on 0114 253 6750 or e mail info@inclusivesheffield.org.uk

Please enter the word/numbers you see in the image below:

Sheffield Centre For Independent Living