Diversity and Disability (DnD)
Membership form

1.  Name:………………………………. 

Surname:……………………………

Address:…………………………………………..………… 

Post Code:…………. Ph:(  )………………………..

Email address:………………………………………

2.  Are you a:    

 Person with a disability from an ethnic background. 		  
If yes, which ethnic group? …………………………… 

  Person interested in self-advocacy, disability and ethnicity.          

3.  How can the Diversity and Disability support you? 
	
     …………………………………………………………………

…………………………………………………………………

4.  Best way to contact you and provide information/support?

 By phone	 By mail		 By email	 Face to face

Signature:………………………………….       

Dated:….……/………./………