Membership Form

Welcome to the Derbyshire Voluntary Action Membership Form. When completing the form fields marked with an asterisk (*) are required information that you will have to complete before submitting.

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Contact Name 1 *

Job Title *

Contact Name 2 *

Job Title *

Organisation Name *

Email Address *

Phone Number *

Organisation Address (Number and Street Name) *

Organisation Address (Town) *

Organisation Address (County) *

Organisation Address (Postcode) *

Website

Social Media Pages

Best Email for general enquiries *

Best Phone Number for general enquiries *

What areas does your organisation serve? *

• Bolsover
• Chesterfield
• Derbyshire Dales
• High Peak
• North East Derbyshire
• All of Derbyshire

Organisation Type *

• Registered Charity
• Voluntary Group
• Community Interest Company
• Social Enterprise
• Company Limited By Guarantee
• Other

Organisation Description (in no more than 100 words)

How many people benefit from your services? (approx.) *

Number of volunteers (approx.) *

We’d like to promote your services, what info would you like us to share? e.g. tell us meeting times/dates, meeting place, purpose, any restrictions on who can attend *

What is your organisations main area of support? *

• Abuse and survivor support
• Advice/information/advocacy/legal
• Alcohol/Substance abuse
• Armed Forces/Veterans
• Arts/Crafts/Culture/Music
• Befriending
• Bereavement
• Campaigning/lobbying
• Carer support
• Children – Parenting and Families
• Community Buildings/Village Halls
• Community development
• Community transport
• Counselling/Therapy
• Crime/Community support
• Disability support/access
• Domestic Violence
• Education/Training
• Faith/Religion
• Funding advice
• Food/Hunger
• Health – Alzheimer’s
• Health – Arthritis
• Health – Cancer
• Health – Eating
• Health – General
• Health – Heart
• Health – HIV/Aids
• Health – Mental Health
• Health – Learning Disabilities
• Health – Palliative Care
• Health – Stroke
• Health – Long Term conditions
• Housing/Homelessness
• Leisure and Recreation
• Men
• Neighbour/Residents association
• Older People
• Parish/Town Council
• Rural Issues
• Self Help Groups
• Social Care
• Social Groups
• Social Welfare Rights/Benefits
• Sports and Exercise
• Unemployment
• Voluntary Sector Support
• Volunteering
• Women
• Young People’s groups/activities

Would you like to receive any of the following from us?

• Derbyshire Voluntary Action bulletin (weekly updates and news which include local activities and support)
• Mental Health bulletin (regular updates and news which include local mental health activities and support)
• Health & Social Care Voluntary Sector Forum invitations (quarterly gatherings to share best practice, network and learn)
• Mental Health Meeting invitations (opportunities to network and hear the mental health updates)
• Network Newsletter (stories and updates from our members)
• Feeling Connected Bulletin (regular updates on reducing loneliness and isolation across Chesterfield and North East Derbyshire)

Would you like to be added to online directories so that people can contact you for support? (this info will be public on DVA website/Community Directory Derbyshire) *

• Yes
• No

Online directory contact details (if different to contact details above)

I agree to my information being used as set out in the Privacy Policy. *

• Yes

Submit