Membership Form

Membership Form 2020

What type of Membership would you like to take up with us? See the different types of Membership Benefits here: onewalsall.org/become-a-member/*
- One Walsall Full Member
- One Walsall Associate Member
Full Legal Name of Organisation (as it appears on your governing document)*
Other name your organisation is known by (Eg: abbreviations)
Type of Organisation*
- Constituted Community Group
- Company Limited By Guarantee
- Faith organisation
- Registered Charity
- Community Interest Company
- Charitable Incorporated Organisation
- Other
Other Type of Organisation:
Charity Number (if applicable)
Company Number (if applicable)
What was your organisation’s income in the last financial year?*
FOR FULL MEMBERSHIP ONLY: Please upload your Organisations Constitution here:
FOR FULL MEMBERSHIP ONLY: Please upload your Organisations Memorandum of Association here:
FOR FULL MEMBERSHIP ONLY: Please upload your Organisations Articles here:
Address of organisation
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Website
Twitter
Facebook
Social Media/Other
Main Contact (This is the person we expect to have day-to-day contact with when delivering support.)*
Title (Mrs, Mr, Ms, Dr.) First Last
Phone
Job Title / Role in organisation
Mobile
Email
Authorised Representative: The Authorised Representative is the person who will represent your organisation at General Meetings and can be nominated to become a Trustee of One Walsall. The Authorised Representative should be someone who holds a senior position in the organisation (e.g. a Senior Officer or Trustee). We can still work with any other member of your organisation in a support capacity. If you wish the Authorised Representative to be the same as the Main Contact, please leave the next section blank.
Prefix First Last
Position/Job Title
Phone
Mobile
Email
Areas Served Please tick all the wards your organisation delivers services in. If you deliver services across the borough, please tick “All Wards”. Being specific about where you operate helps us to provide information relevant to your organisation.
- All Wards
- Aldridge Central & South
- Aldridge North & Walsall Wood
- Bentley and Darlaston North
- Birchills Leamore
- Blakenall
- Bloxwich East
- Bloxwich West
- Brownhills
- Darlaston South
- Paddock
- Palfrey
- Pelsall
- Pheasey Park Farm
- Pleck
- Rushall Shelfield
- Short Heath
- St Matthew’s
- Streetly
- Willenhall North
- Willenhall South
Primary Type of Service offered by your Organisation (select one)*
Other types of services: Being specific about the services your organisation delivers helps us to provide you with relevant information.
- Accommodation
- Advice & Information Services
- Advocacy
- Animal Welfare
- Arts and media
- Befriending
- Campaigning
- Carers’ Support
- Catering
- Childcare
- Community Development
- Community Services / Facilities
- Counselling and Therapy Services
- Crime / Community Safety
- Day Care Services
- Domestic Abuse / Sexual Abuse
- Driving
- Education - Out of School Alternative
- Education / Training - General Employment Support
- Environment / Conservation
- Faith / Religion
- Family / Parenting Services
- Financial Services
- Grant Making
- Health - Mental
- Health – Sexual
- Health & Wellbeing - General
- Homelessness
- Housing
- International Aid
- Lunch Clubs
- Mediation
- Mentoring
- Regeneration
- Relief of Poverty / Low Income
- Social and Community Care Services
- Social Activities
- Sports and Leisure
- Substance Misuse
- Telephone Helpline
- Tenants and Residents
- Translation & Interpreting
- Transport
- Voluntary and Community Sector Support
- Volunteering
- Youth Work and Clubs
Please can you give us more detail of the non-profit activities your group carries out in the Walsall area, i.e. venues used, volunteer activities, sessions run.
Primary Client Group your Organisation Supports:*
Other Client groups: Being specific about who your organisation serves helps us to provide you with relevant information. Please indicate your organisation’s main (primary) client group:
- Black & Ethnic Minority (All)
- BAME (Afghan)
- BAME (Bangladeshi)
- BAME (Black African /Caribbean)
- BAME (Eastern European)
- BAME (Indian)
- BAME (Other)
- BAME (Pakistani)
- Carers
- Children – Early Years (0-5)
- Children (6-19)
- Disability – Learning Disabilities
- Disability – Sensory/Physical Impairment
- Faith Groups
- Families/Parents
- Gay/Lesbian/Bisexual/Transgender
- Homeless People
- Long – Term Chronic Illness (people with)
- Low Income
- Men
- Mental Health Problems (people with)
- Offenders / Ex-Offenders
- Older Adults (over 55)
- Refugees / asylum Seekers
- Social Entrepreneurs
- Substance Misusers
- Tenants and Residents
- Travellers
- Unemployed
- Victims of Crime / Survivors of Abuse
- Voluntary and Community Groups
- Volunteers
- Women
- Young People (19-25)
Walsall Locality Covered:
- Select All
- North
- South
- East
- West
Declaration, Please tick all the boxes to confirm:*
- I have the authority to complete this membership form on behalf of your organisation
- I commit to One Walsall’s Aims Values and Objects
- I meet the criteria for One Walsall membership
- I agree for One Walsall to hold our details on our Members’ Database
- Your email address will be added to the One Walsall Mailing List and Newsletter List
One Walsall is a Company Limited by Guarantee. Member organisations will be included on the Company Register of Members. In the event of One Walsall being wound up members may be required to pay the sum of £1.
I agree
Name
Signature
Date
Date Format: DD slash MM slash YYYY
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Membership Form 2020

Charity Number: 1074659