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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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.)* DrMissMrMrsMsProf.Rev. Title (Mrs, Mr, Ms, Dr.) First Last PhoneJob Title / Role in organisationMobileEmail 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. DrMissMrMrsMsProf.Rev. Prefix First Last Position/Job TitlePhoneMobileEmail 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)*AccommodationAdvice & Information ServicesAdvocacyAnimal WelfareArts and mediaBefriendingCampaigningCarers’ SupportCateringChildcareCommunity DevelopmentCommunity Services / FacilitiesCounselling and Therapy ServicesCrime / Community SafetyDay Care ServicesDomestic Abuse / Sexual AbuseDrivingEducation - Out of School AlternativeEducation / Training - GeneralEnvironment / ConservationFaith / ReligionFamily / Parenting ServicesFinancial ServicesGrant MakingHealth - MentalHealth – SexualHealth & Wellbeing - GeneralHomelessnessHousingInternational AidLunch ClubsMediationMentoringRegenerationRelief of Poverty / Low IncomeSocial and Community Care Services Social ActivitiesSports and LeisureSubstance MisuseTelephone HelplineTenants and ResidentsTranslation & InterpretingTransportVoluntary and Community Sector Support VolunteeringYouth Work and ClubsOther 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:*Black & Ethnic Minority (All)BAME (Afghan)BAME (Bangladeshi)BAME (Black African /Caribbean)BAME (Eastern European)BAME (Indian)BAME (Other)BAME (Pakistani)CarersChildren – Early Years (0-5)Children (6-19)Disability – Learning DisabilitiesDisability – Sensory/Physical ImpairmentFaith GroupsFamilies/ParentsGay/Lesbian/Bisexual/TransgenderHomeless PeopleLong – Term Chronic Illness (people with)Low IncomeMenMental Health Problems (people with)Offenders / Ex-OffendersOlder Adults (over 55)Refugees / asylum SeekersSocial EntrepreneursSubstance MisusersTenants and ResidentsTravellersUnemployedVictims of Crime / Survivors of AbuseVoluntary and Community GroupsVolunteersWomenYoung People (19-25)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 agreeNameSignatureDate Date Format: DD slash MM slash YYYY CAPTCHA