Community Membership Application Form

Name:

Job Title:

Contact Number:

Contact Email:

Website:

Address:

Postcode:

Membership Type:
—Please choose an option—Full membershipAssociate membershipCommunity rehabilitation membershipPartner Membership

Name:

Holding Company:

Provider Name:

Registered Manager (if applicable) :

Service Manager (if Different):

Lead Professional:

Lead Contact:

Key Contacts:

Marketing Lead:

HR/Recruitment Lead:

Research Lead:

Services Provided:

Community Bedded Rehabilitation UnitOutpatients (facility based)Domiciliary (including nursing home)Provision within another service eg Rehab Units

Therapies Provided:

Arts TherapiesDieteticsNeuropsychologyOccupational TherapyPhysiotherapy PsychologySpeech & Languauge TherapyOther