SSJ Service User & Residents Association (SURA): Registration Form

You are completing this form because you wish to register yourself as an SSJ Service User & Residents Association member. You are not obliged to attend any meetings or receive any notifications or additional information, but registration will mean that you are able to vote on any matters to do with the the association.

Name *

Address

Address Line 1

City

State / Province / Region

Postal Code

Contact Number

1. Your SSJ Status

Please select either 1 or 1 & 3 or 2 or 2 & 3

2. Tick this box if you would like to be kept informed about SURA activities

3. How would you like us to contact you? - Select all that apply

4. What information would you like to receive? - Select all that apply

5. SURA has a fifteen person capacity on its committee, of which there are available spaces. Please tick Yes below, if you would like to join the committee or tick I'd like to receive more information and SURA will respond.

Yes
No
I'd like to receive more information

Health & Wellbeing

1. Do you have any health conditions and/or support needs which SURA should be aware of? *

Yes
No
Prefer not to say

If Yes, then please complete the following If you prefer not to say, SURA may enquire with your consent, as to why you prefer not to say.

2. Please describe your medical, health condition/s and/or support needs and how it/they might affect your interactions with SURA and what SURA can do to support you?

Please continue below if you need to.

Health & Wellbeing continued....

GDPR Agreement: I consent to allowing The Society of St James (SSJ) to store my submitted information so they can respond to this registration. *

Your personal data will ONLY be used for the purposes of this SURA registration and communication.