PERSONAL DETAILS

NAME:

ADDRESS:

POST CODE:

E-MAIL:

TELPHONE:

SUBSCRIPTION

I would like to become a member of DAG and enclose a payment of £3.50:

I enclose a donation of £.......

ADDITIONAL INFORMATION

If you were to attend our events, would you use/need any of the following (please tick) :

Wheelchair :

Creche :

Personal assistant :

Large print information :

Assistance with transport:

Other (please state) ..........................................................

To enable the group to target its services more effectively, we would be grateful if you could also complete the following :

Are you (please tick):

A disabled person:

A carer:

A representative from another organisation

Please state name of other organisation

....................................................................