Senior Council for Devon

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Senior Council for Devon Membership Form for Individuals

Your personal information and Data Protection Notice

The information which you provide on this form will be held by  the Senior Council for Devon. This information will be used by the Senior Council for the purposes of keeping in contact with members and involving them in the way they prefer.

Your personal information will be kept secure and will not be held for any longer than is necessary. We will not disclose any information which would identify you, to anyone else, unless you give us your permission to do so. If you have any queries about this, please contact the Senior Council for Devon.

Name
Address
Post Code
Senior Council market or coastal town area.


( See Map- please select the area you most identify with if unsure of the boundary)
Telephone Number
Email address
How you would like to be involved (You can change your involvement at any time by contacting us).

Please tick ALL the boxes that are right for you

Receiving information out about local services
Taking part in consultation about local services
Event/meeting attendance
Helping run my local senior council
Contributing your skills and time in other ways*

*If yes please give details

The senior council aims to give voice to issues that you may have with the intention of changing things for the better.

What are your top three concerns

1
2
3

Description of any skills and interests you have
Information about you – OPTIONAL

The Senior Council for Devon is open to ALL people aged 50+. To ensure that we are representative / inclusive and reflect the older population across Devon, it would help us to know a little bit about you.

Gender:
Male
Female


Age bands:
50-59
60-69
70-79
80-89
90+

Ethnic group:

White British White European

Mixed White
White and Black Caribbean
White and Black African
White and Asian

Any other mixed background- please write in

Asian or Asian British: Indian
Pakistani Bangladeshi

Any other Asian background – please write in

Black or Black British: Caribbean

African

Any other Black background – please write in

Chinese or other ethnic group: Chinese

Any other ethnic group – please write in

I’d prefer not to answer


Other groups or organisations that you belong to for people 50+

Preferred method of communication:
By post By email
(Email is more environmentally friendly)

Senior Council for Devon,
PO Box 210,
Harberton,
Totnes,
TQ9 9DA

Signed

Date
 

 

SCfD email contact is info@scfd.org.uk