Health Alliance Membership Form

Health Alliance Membership Form
1. What is the name of your group/organisation?
2. Which sector do you represent? (Please tick)
Community
Voluntary
Other
Please state:
Statutory
3. Your name:
4. What is the full postal address (including post code) of your
group/organisation?
5. Contact telephone number:
6. Email address:
7. How many members are in your community group:
8. What setting is the community group / organisation based within
Rural
Urban
9. How often does the community group meet:
Health Alliance Membership Form
10. What main areas of health & social wellbeing have the group been
involved in the past (last 3 years):
11. What areas of health & social wellbeing would the group be interested in
developing in the future:
12. What support, if any, would the group like in the future to develop areas
of health and social wellbeing improvement?
13. Would you be interested in a visit from a NICHI Officer to discuss your
group’s needs and interests around health & wellbeing further?
Yes
No
14. Any other information or comments