Peterborough and District Deaf Childrens Society

Charity Registration Number 1053815

Membership Form
Parent or carer info Relationship to child / Parent Carer Other_______________ I am a Professional Working For _________________________ Please print clearly and Circle where appropriate Title Mr / Mrs / Miss / Ms First Name: _________________ Address Line 1 : _____________________________ Line 2: _____________________________ Line 3: _____________________________ Town: _____________________________ County: ___________________ Post code: ________________ Home phone: ______________ Mobile: ________________ Email _______________________@____________________ Surname: _______________

This is used to keep you up to date with things that are going on. From time to time we send out updates please state preferred way of receiving them it could be post and/or e-mail if required () Please send me email update () Please send me postal update () Both

Depending on age of child or with permission from the appropriate adult. We would like to be able to contact your child (This info may be used for the older children e.g. Youth group) () I am happy for my child / Young Person to be contacted directly My Contact Details and return address Membership Officer Dean Monaf 5 Kilham Orton Goldhay Peterborough PE2 5SU Dean.Monaf1@ntlworld.com 01733390599 / 07977409611 I am happy to send and receive this form by email

P.T.O Childrens details overleaf 1st Child details

Text/phone: 07806429547E mail: peterborough@ndcsgroup.org.uk Website: www.pddcs.co.uk

Peterborough and District Deaf Childrens Society

Charity Registration Number 1053815 Child's first name________________ Child's gender Male Female Child's surname ________________

Date of birth (Date Month Year) _______ / ____________/ _____________ Mobile: ____________________ E-mail: _____________________________ Deafness type: Mild Moderately Severely - profoundly deaf Other __________________ Equipment used: Bone anchored hearing aid Cochlear implant: one ear or both ears Hearing aid: one ear or both ears Other:__________________ Child's preferred method of communication: Sign language Speech

Both

Too young to say

2nd Child details Child's first name________________ Child's gender Male Female Child's surname ________________

Date of birth (Date Month Year) _______ / ____________/ _____________ Mobile: ________________________ E-mail: _____________________________ Deafness type: Mild Moderately Severely - profoundly deaf Other __________________ Equipment used: Bone anchored hearing aid Cochlear implant: one ear or both ears Hearing aid: one ear or both ears Other:__________________ Child's preferred method of communication: Sign language Speech

Both

Too young to say

Other siblings Child's name________________ Child's gender Male Female Child's surname ________________

Date of birth (Date Month Year) _______ / ____________/ _____________ Child's name________________ Child's gender Male Female Child's surname ________________

Date of birth (Date Month Year) _______ / ____________/ _____________

Data protection We use your data to send you information about PDDCS services and activities as appropriate to your personal needs. This data will not be shared with any other party without your explicit permission.

Text/phone: 07806429547E mail: peterborough@ndcsgroup.org.uk Website: www.pddcs.co.uk