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Enquiries@megancic.org.uk

01634 402077

To become a member of MEGAN CIC and access our peer support groups, please fill out the short form below and submit and you will hear from us as soon as possible

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Full Name *

Address *

and our GP

Postcode *

Contact Number *

Email Address

Date Of Birth *

GP Surgery

Do You Have A Mental Health Diagnosis? If Yes, Please State Below

Where Did You Hear About MEGAN CIC

Gender

• Male
• Female
• Transgender
• Other Gender Variant

Do You Consider Yourself To Have A Disability

• Yes
• No

Sexual Orientation

• Bisexual
• Gay Man
• Gay Women / Lesbian
• Questioning
• Heterosexual
• Other

Ethnicity

• White -English / Scottish / Welsh / Northern Irish / UK
• White – Irish
• White – Gypsy Or Irish Traveller
• White – Any Other White Background
• Mixed Ethnic Background
• Asian / Asian UK – Indian
• Asian / Asian UK – Pakistani
• Asian / Asian UK – Bangladeshi
• Asian / Asian UK – Chinese
• Any Other Asian Background
• Black / African / Caribbean / Black UK – African
• Black / African / Caribbean / Black UK – Caribbean
• Any Other Black / African / Caribbean Background
• Other Ethnic Group – Arab
• Other Ethnic Group – Any Other

Religion Or Belief

• No Religion
• Christian
• Buddhist
• Hindu
• Jewish
• Muslim
• Sikh
• Other Religion

Photo / Video Consent – The staff and volunteers at MEGAN CIC may, on occasion, wish to take photographs and / or video footage of you at group events and activities organised by MEGAN CIC. The reasons include: – To have a visual record of the event, to advertise and promote the services both local and nationally, to show to our funders and / or to use as a tool to seek funding, to update MEGAN CIC website / social media on the internet, to promote health and wellbeing initiatives.

• Please tick if you give consent to the taking of photographs and / or video film to be used as outlined above.

General Data Protection Regulations (GDPR) Statement – We keep a record of the following information: name, address, contact number, email address, date of birth, mental health diagnosis, GP, where you heard about MEGAN CIC, equality and diversity data and records relating to the support you receive from MEGAN. The information is used for monitoring purposes, to enable the distribution of relevant information and in case of an emergency or safeguarding concern; we would provide any relevant information to paramedics, police, and / or general health professionals. Your information will be held by MEGAN CIC on our Client Management System for the duration of your membership. MEGAN CIC would never sell, give out or distribute any details you have provided other than that outlined previously. All information collected is stored in line with the General Data Protection Regulations. Confidentiality Statement – MEGAN CIC take confidentiality very seriously. Anything discussed or disclosed within the groups will be kept confidential within MEGAN CIC. Group Facilitators and Directors reserve the right to breach this confidentiality statement for the following reasons: If there is a risk of harm to yourself, others or local / national security, where a worker is summoned by a court to give evidence, in an emergency i.e. if the medical services or police were needed, if we have concerns for a child’s welfare we will raise this as a child protection issue or concerns for a vulnerable adult this will be raised as a safeguarding issue with the appropriate persons. *

• Agreement – I confirm that I have read, understood and agree for MEGAN CIC to hold my details as listed under the GDPR Statement for the purposes outlined and the MEGAN CIC Confidentiality Statement. You have the right to opt out at any point by contacting us when we will then dispose of your information securely.

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