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ENFIELD SAHELI
EMPOWERING WOMEN


MEMBERSHIP FORM


The information will be treated as confidential and used solely for monitoring purposes.

ANNUAL MEMBERSHIP FEE £10.00

The membership expires on the last day of March every year



Preferred Language
Your Title
Marital Status
DOB
Surname
Forenames
Age Group 25-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84
Phone/Mobile
Email
Address
GP`S NAME
Phone
Address
Are you disabled?
If yes Physical Disability OR Mental Disability, Please state
Are you receiving any state Benefits?
If yes please state
Are you a Carer?
If Yes, Who do you care for?
Age
Any Medical Condition ? Please give us more details on medication
ETHNIC ORIGIN
How would you describe your Ethnic background? BLACKMAURITIUSSRI-LANKANBANGLADESHIINDIANPAKISTANINot StatedOTHERS
Religion: Please Specify here HinduismIslamChristianityNot statedOthers
Sexual Orientation: Please Specify here BisexualHeterosexualGay Woman/LesbianNot statedOthers
NEXT OF KIN
Friend or relative we can contact in emergency
Name
Relationship
Where did you hear about Saheli?
I agree to the Saheli Code of Conduct
Declaration of Interests

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