Membership Form Membership TypesWe currently offer two memberships. Which membership are you applying for?*Tick whichever best applies to your organisation currently. Full Membership (for organisations with a constitution) Associate Membership (for grassroots organisations who have not yet developed a constitution - or who wish to remain unconstituted) Are you an individual or a group?* Individual Group Constitution*In order to move forward with Full Membership, it is required that you upload your constitution. Organisations that have not developed a constitution or wish to remain unconstituted, are eligible for Associate Membership only.About your organisationWe ask you for your organisation's governing document so we can review your applicationName of Organisation*(as stated on governing document)Name of Organisation*Any other name your organisation is known byOrganisation type*(tick all that apply) Charitable Incorporated Organisation Community Interest Company Company Limited by Guarantee Constituted community group Faith Organisation Registered Charity Other (please state)Charity Number(if applicable)Company Number(if applicable)Business address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican 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 RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican 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 RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Website Twitter accountFacebook accountWhat was your organisation's income in the last financial year?*Under £1000£1000-£10,000£10,001 to £50,000£50,001 - £100,000£100,001 - £250,000£250,001 - £500,000£500,001 - £1m£1m+Main ContactThis is the person we expect to have day-to-day contact with when delivering support.Title*Name* First Last Position/Job Title*Main telephone number*Mobile numberEmail* Authorised RepresentativeThe 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 member of your organisation in a support capacity.Title*Name* First Last Position/Job Title*Main telephone number*Mobile number*Email* Consent I agree to the privacy policy.About your OrganisationAreas Served*Please select all the wards your organisation delivers services in. If you can 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 South Willenhall North Main types of service*Being specific about the service your organisation delivers helps us to provide you with relevant information. Select up to 4. Accommodation Advice & Information Services Advocacy Animal Welfare Arts and media Befriending Campaigning Careers Support Catering Childcare Community Development Community Services / Facilities Counselling and Therapy Services Crime / Community Safety Day Care Services Dementia Care Domestic Abuse / Sexual Abuse 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 Homeslessness Housing International Aid Lunch Clubs Mediation Mentoring Regeneration Relief of Poverty / Low Income Social Activities Social and Community Care Services Sports and Leisure Substance Misuse Telephone Helpline Tenants and Residents Translation & Interpreting Transport Voluntary and Community Sector Support Volunteering Youth Work and Clubs OtherPlease state:Client groups*Being specific about who your organisations serves helps us to provide you with relevant information. Select up to 4. Black & Ethnic Minority (All) BAME (Afghan) BAME (Bangledeshi) BAME (Black African / Caribbean) BAME (Eastern European) BAME (Indian) BAME (Pakistani) BAME (Other) 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 Victim of Crime / Survivors of Abuse Voluntary and Community Groups Volunteers Women Young People (19-25) Declaration*Please tick all the boxes to confirm: You have the authority to complete this membership form on behalf of your organisation You commit to One Walsall's Aim, Value and Objects You meet the criteria for One Walsall membership You agree for One Walsall to hold your details on our Members' Database. Your email address may be added to the One Walsall Members mailing list Company Register of Members*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. GDPR*Please tick to confirm you have been given explicit consent from the Authorised Representative to share this information and contact details for the purpose of applying for One Walsall Membership This application form will be stored electronically and kept for 24 months from the date of the acceptance.All personal data will be held securely and in accordance with General Data Protection Regulation (GDPR). One Walsall is committed to ensuring that privacy is protected. Should we ask you to provide certain information by which you can be identified, you can be assured that it will only be used in accordance with our privacy statement. One Walsall Full Privacy Notice can be found in the Menu at the top of the page. I agree Full membership* I understand that I will need to reapply for membership after 2 years.Associate Membership* I understand that this membership is time limited.Associate membership for individuals is for 6 months. Associate membership for organisations is for 2 years.Privacy Policy, Aims, Objects and Values*I have read and understood the contents of the Aims, Objects and Values page, as well as the Privacy Policy, before completing this application for membership. I agreeAbout youPlease detail below information about the person who has completed this form.Name* First Last Date* Date Format: MM slash DD slash YYYY Role*The next stepsWe will contact you to confirm receipt of your form and the next steps. If you have any queries, please contact us on 01922 619 840.