Membership Form 2023

The Basics
Please tell us about yourself
First Name*
Second Name*
Known As*
Date of Birth*

Day
Month
Year
What are your contact details?
Mobile*
Home Phone*
Email Address*
Address*
Street Address City ZIP / Postal Code
Who should we contact in an Emergency?
Name
Relationship to you
Phone
Alternative phone (if they have one)

Volunteering or becoming a member
Tick which applies below?*
(you must tick one)
- I wish to VOLUNTEER and am not looking to take-up any services or support
- WE ARE NOT ACCEPTING NEW REFERRALS UNTIL JANUARY 2024 - I am referring myself and looking to attend classes, take part in groups and access support and services. (I may decide later to volunteer or am happy to volunteer if asked)
You should tick the referring yourself option even if you are getting help filling in this form from a support worker or family member. We will ask for their details later.

References & info regarding Volunteering
Please can you provide the details of two character referees whom we can contact to ensure you are who you say you are and keep our members and community safe.
This must not be family member or partner.
REFEREE 1
Name*
Company
Email Address*
Phone Number*
REFEREE 2
Name*
Company
Email Address*
Phone Number*
In addition to providing two character references you must complete a PVG membership form (police Clearance check), which is FREE and we will forward to you.*
Please tick below to confirm you have read and agree to this.
- Yes, I agree to completing a PVG form
- No, not at this time

Doctor
Please state name, address and contact number of your Doctor
Name
Phone
Surgery / Medical Centre name
Do you have a referrer or Support Worker?*
- Yes
- No
Please note: Regrettably ticking the above not guarantee you to or entitle you to any of these services or support. We have limited resources and target some of these at people who are most in need or vulnerable. If you are concerned for your own safety, health or wellbeing or feel you require emergency assistance please contact your GP, a social worker or the Police. Useful numbers: Social Care Direct 0131 200 2324 / Police 101 / Samaritans 116 123.

More details about your Support worker or referrer
Please provide the details of this referrer / support worker
Name*
Job Title*
Phone*
Email*
Agency / Organisation*
Address*
Postal Code*

Confirmation, Certification & Consent
We have four very important questions below.
DECLARATION / CERTIFICATION:
I realise that false information or omissions contained in this form may affect my position as a member or volunteer with the Grassmarket Community Project. I understand that should I incur any criminal convictions after filling in this form I must inform the Grassmarket Community Project. By ticking yes I am confirming all the details contained in the form are correct to the best of my knowledge and understanding.
*
Yes, I confirm the details I have submitted are correct to the best of my knowledge and understanding.*
PHOTOGRAPHY:
I understand that from time to time the Charity may take photographs for publicity purposes and share these on social media and/or within internally published documents.
*
Yes, I will notify who ever is taking the photograph, when asked if I do not wish to be in any photograph being taken for the Grassmarket's publicity purposes.*
DATA HELD BY THE GRASSMARKET COMMUNITY PROJECT:
Your personal information will be held and used in accordance with data protection legislation if you confirm your consent to this by ticking the appropriate boxes below.
• I consent to my personal information being used by the Project to facilitate and support my participation in activities and internal administration purposes including monitoring activity attendance.
• I consent to my anonymised data being used to further the Project’s charitable aims including statistics for funding and monitoring purposes.
I consent to being contacted by the Project, to keep in touch and tell me about news and events of interest to the community by: Please indicate below:
*
- Phone
- Email
- Text
- Post
- Social Media
DATA HELD BY THE GRASSMARKET COMMUNITY PROJECT:
The Charity will only hold your information while you are actively engaged with the community. You can withdraw your consent to your data being held by calling the Grassmarket Centre on 0131 225 3626 or emailing info@grassmarket.org
Your personal information will not be shared with any other company or organisation without your permission, except where required by law. For example, communicating with statutory services such as police or social workers when they request information. We will do this with your full knowledge where possible.
The Charity collects information on criminal convictions on the condition this is required for the legitimate activities of the Charity. The Charity collects information on health on the condition this facilitates the provision of social care.
*
I confirm I have read, understood and agree to the above statements.*
Thank you for completing the form - PLEASE SUBMIT and we will get in touch to arrange an informal welcome conversation. If you dont hear from us within 10 days please contact info@grassmarket.org or call 0131 225 3626

Step 1 of 10

The Basics

Please tell us about yourself

What are your contact details?

Who should we contact in an Emergency?

Volunteering or becoming a member

References & info regarding Volunteering

REFEREE 1

REFEREE 2

Doctor

Please state name, address and contact number of your Doctor

More details about your Support worker or referrer

Please provide the details of this referrer / support worker

More about you

Strengths & Experiences

Helpful Feedback for us

Equal Opportunities & Inclusion Monitoring

Confirmation, Certification & Consent

DECLARATION / CERTIFICATION:

PHOTOGRAPHY:

DATA HELD BY THE GRASSMARKET COMMUNITY PROJECT:

DATA HELD BY THE GRASSMARKET COMMUNITY PROJECT:

Membership Form 2023

Step 1 of 10

The Basics

Please tell us about yourself

What are your contact details?

Who should we contact in an Emergency?

Volunteering or becoming a member

References & info regarding Volunteering

REFEREE 1

REFEREE 2

Doctor

Please state name, address and contact number of your Doctor

More details about your Support worker or referrer

Please provide the details of this referrer / support worker

More about you

Strengths & Experiences

Helpful Feedback for us

Equal Opportunities & Inclusion Monitoring

Confirmation, Certification & Consent

DECLARATION / CERTIFICATION:

PHOTOGRAPHY:

DATA HELD BY THE GRASSMARKET COMMUNITY PROJECT:

DATA HELD BY THE GRASSMARKET COMMUNITY PROJECT:

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