FULL & ASSOCIATE
MEMBERSHIP
I/we wish to become: A Full Member:
An Associate Member:
(fee payable £30: see notes overleaf)
of The Dartford & Gravesham Consortium Ltd
NAME(S) OF PARENT OR GUARDIAN (Please Print):
1) ……………………………………………….….…………………………………..…………………….............
2) ………………………………………….………………………………………..………………….................….
Address: ……………………………………………………………………………………………………………..
…………………………………………………………………………………Postcode:…………….………………
Telephone: …………………………....……………………………………. ……………………………………….
E-mail address: …………………………..……………………………………………………………..…. ………..
Please complete the following information for each disabled child:
CHILD/YOUNG PERSON’S NAME: .………..…………………………………………………………………………………..
CHILD/YOUNG PERSON’S IMPAIRMENT: ( i.e: Autism, Cerebral Palsy):
………………………………..…………………………..................................................................................................…..
CHILD/YOUNG PERSON’S DATE OF BIRTH: ………………....…………………………………….……………
CHILD/YOUNG PERSON’S NAME: ...................................……………………..………………...………….………………
CHILD/YOUNG PERSON’S IMPAIRMENT: ( i.e: Autism, Cerebral Palsy):
.........................................................................................................................................................................................
CHILD/YOUNG PERSON’S DATE OF BIRTH: …....……………………….......……......………………………
SIBLINGS DETAILS:
Name………………………………………………….. Date of Birth: .................................................................
Name………………………………………………….. Date of Birth: .................................................................
Name…………………………………………………… Date of Birth…………………………………………………
1) SIGNED: ……………………..……………………….......….……...
Date: …….………………………………………………
2) SIGNED:..…………….………………………
Form received from: .............................................................
PTO
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You will receive the newsletter and correspondence via your email address unless otherwise
requested………………………………………………………………………………………………………………….
Ethnic Origin (please circle as appropriate):
British Asian
Other Asian
Black British - Afro/Carib
Black British - Other
Black Other
Chinese
Mixed Race
White British
White Irish
Not Known
Not provided
I wish to pay £……………… by cash/cheque/PO/Debit Card/Bank transfer:
Full year/half year (delete as appropriate) & make cheques payable to “The Parents
Consortium” please.
I am a tax payer and I have/have not completed a Gift Aid Form (please delete as
appropriate)
Notes
The Parents Consortium is a Charitable Company. To become a full member of the Consortium,
you need to be the parent or guardian of a disabled child aged under 19 years and living in the
Dartford, Gravesham or Swanley areas - all full members have the option to become voting or
non-voting (Associate) members. Membership will cost £30 per year.
This can be paid in 2 x 6 monthly instalments.
 A Voting member has the right to receive services, the newsletter, ability to hire the
premises for special functions at a reduced rate and full voting rights at General Meetings, as
well as eligibility for election to Council of Management. The Parents Consortium is a
Company limited by guarantee and the extent of the liability per individual is £5.00.
 A non-voting (Associate) member receives the services and newsletters as above but
has no legal liability and is not entitled to a vote. An Associate Member may stand for election
on to the Council of Management.
All enquiries to the General Office – 01322 668501; Fax: 01322 660230
Email: admin@parentsconsortium.co.uk
www.parentsconsortium.org.uk
Please return this form to: Allsworth Court, 40 St David’s Road, Hextable, Kent BR8 7RJ
Each person who wishes to be a member must sign this declaration form. The information disclosed will be held on a
database and will be used within The Parents Consortium only. It will not be given to a third party.
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