Disabled Parents Network
Freepost RSJZ- TKAE- CYZJ
1a Humphrys Road, Woodside Estate
Dunstable, LU5 4TP
0300 3300 639
information@disabledparentsnetwork.org.uk
Membership form
Our vision is of a society in which people with a disability or long-term health
challenge can freely aspire to be parents and enjoy a full and rewarding family life
with their partners and children. In disabled parent families, children are free to
enjoy their childhood. Health, social care and education services are easy to
access and disabled parent families routinely receive the support they need.
DPN membership is open to anyone who considers themselves disabled or
affected by a long term health condition who is, or wishes to become a parent
and their partners.
We also offer Associate Membership to other individuals and organisations who
support disabled parent families and wish to support us.
As a user-led organisation members are important to us. We appreciate your
views and opinions. Membership is free to all disabled parents and their partners.
As a member you will receive a regular newsletter and have access to our Peer
Support Register, which can put you in touch with others in a similar situation or
with a similar disability or health condition.
If you would like to become a member of DPN, please fill in this form below. (You
can cancel your membership with DPN at any time.) You can print it off and return
to the address above or email it to information@disabledparentsnetwork.org.uk
This form can also be used by current DPN members to amend their details or
cancel their membership.
Storage and use of your information
DPN will store and use your details in line with the requirements of the Data
Protection Act 1998 and DPNs Confidentiality, Information Security and Privacy
Policies.
Contact DPN
DPN can be contacted for administrative issues c/o Disabled Parents Network,
Poynters House, Poynters Road, Dunstable, Bedfordshire, LU5 4TP. You can
phone DPN on 0300 3300 639 or email
information@disabledparentsnetwork.org.uk
Disabled Parents' Network is a Company registered in England and Wales, no 4147323
at Poynters House. Poynters Road. Dunstable Beds., LU5 4TP. Registered Charity No 1087662
Membership form
Your Title:____ Your First Name:____________Your Surname:____________
Your Address:_____________________________________________________
_________________________________________________________________
Your Postcode:_____________
Your Local Authority Area:___________
Your landline number:______________________________________________
Your mobile number:_______________________________________________
Your email address:________________________________________________
How did you find out about DPN?______________________________________
Please remove me from your database (please tick):
______
Please tell us your preferred way to receive information from DPN
(please tick) (If you do not tick a box; default is email standard)
Email Standard ___ Email PDF ___ Email Plain Text ___ Post Standard___
Email large font ___ Post large font ___
Audio ___
If you have selected large font please tell us your preferred font size:__________
Membership – What type of member would you prefer to be?:
 A full member (disabled parent or partner) but do not wish to vote at or take
part in meetings
__________
 A full member (disabled parent or partner) and wish to take part in Annual
General Meetings and the decisions of DPN (either attending meetings or
casting a vote by proxy)
__________
 An Associate Member/Member organisation (professional/professional
organisation supporting disabled parent families) (Cost £15 p/a)__________
Subscriptions, donations and Gift Aid
If you are a full member there is no charge to join DPN, although we welcome
donations from members and supporters at any time. Donations can be made by
cheque addressed to “Disabled Parents Network” or via the “PayPal” button on
our website www.disabledparentsnetwork.org.uk.
Even if you are not donating at this time, by ticking the Gift Aid declaration below
you will be helping DPN. This does not cost you a penny but means that DPN can
claim an additional 28p from Inland Revenue for every £1 we receive from you by
way of donations (inc. purchase of raffle tickets etc) at any time in the future.
Gift Aid Declaration
I (name)________________________________ am a UK taxpayer and would
like to Gift Aid any donations made by me to Disabled Parents Network so that
they can reclaim tax on it.
Tick to Agree _______
If you are applying for Associate Membership you can pay your membership
subscription by cheque or via the PayPal button (as described above), if however
you require an invoice to be raised for your subscription please complete the
details below:
Invoice To: ___________________ Organisation name:____________________
Invoice address:____________________________________________________
_________________________________________ Postcode:_______________
Additional information to be included in the invoice:_________________________
_______________________________ Purchase Order No (if required):________
Please tell us about the types of disabilities/health issues that
affect you (please tick):
___ None
Hidden
___ Hearing
___ Visual
___ Learning ___
Mental Health
___ Physical Health ___ Physical Impairment
___
You can tell us more about your health issues/disabilities here if you want to:
________________________________________________________________________
________________________________________________________________________
Peer Support Register (available to Full members only)
One of the benefits of membership is that you can join our Peer Support Register.
You can receive details of other members and you can be included in the Peer
Support Register yourself. Any details shared will be by your agreement but DPN
cannot take responsibility for any contact that you may then go on to make or
receive. Would you like to join the Peer Support Register? (please tick)
Yes to receive details of other members
_____
Yes for my details to be included. Other members can contact me
_____
Yes to receive and be included in the Peer Support Register
_____
No
_____
Information I am willing to share (please tick) (if other please include your
preferred contact details)
Email address: ________________
Mobile phone number: _____________
Other: ___________________
If you wish to receive contact details from the Peer Support Register would
you like this to be (please tick)
People who have similar disability/health issues to me:
___
People who live in my area:
___
Monitoring
This data is collected for monitoring purposes (you do not have to complete this
section if you do not want to):
Your gender:___________
Your ethnicity:_________________________
Your marital status:________________________________________________
Your age – Are you (please tick)
Under 16:___
51-65:___
16-20: ___
65+:___
21-30:___
31-40:___
41-50:___
Your parental status - Are you (please tick):
A parent to be:
____
From a two parent family (disabled Mum):
____
From a two parent family (disabled Dad):
____
From a two parent family (both disabled):
____
A single mother:
____
A single father:
____
Tell us about your children (if appropriate):
I am a parent to be, my baby is due on: _______________________
Child 1
Name:__________________ Age:___ M/F:___ Currently living with:__________
Child 2
Name:__________________ Age:___ M/F:___ Currently living with:__________
Child 3
Name:__________________ Age:___ M/F:___ Currently living with:__________
Child 4
Name:__________________ Age:___ M/F:___ Currently living with:__________
Do any of your children have a disability (if yes tick who) 1:___ 2:___ 3:___ 4:___
Please use this section to tell us anything more about you that you think is
relevant:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Disabled Parents Network is a Company registered in England and Wales,
No: 4147323 and a registered Charity No: 1087662.
Registered Office: Poynters House. Poynters Road. Dunstable. Beds. LU5
4TP