Special Interest Group for Children With Special Needs

Membership Application Form

Please provide the following contact information:

*First name

*Last name

*Title

*Occupation

*Address

 
 
 

*Postal code

*Work Phone

Fax

*E-mail

*Home Address

 
 

*Postal code

*E-mail

Fax

*Home Phone

   

*Membership No.

   

*Employing Trust/Authority .

*Any Previous Relevant Experience.

*Special Interests Relevant to the Group.

   

*Are you prepared to be contacted for your opinion in relation to your experience and interests?

   

*Are you prepared to be read and comment on documents in relation to your experience and interests?

   

*Can this form be held on the Committee Representative home computer for use by the SIG for Special Needs and the CPHVA?

*Date

Subscription fee is £10 for year from October 2001

Please make cheques payable to: SIG for Special Needs and post to:


Child Development Service
6th Floor, QEQM Wing
St Mary;s Hospital
Praed Street, London
W2 1NY

Tel. 0208 886 1450
Tel. 0208 886 6102

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