Please return to: Norah Sanders Middlesbrough Voluntary Development Agency, St Mary’s Centre, 82-90 Corporation Road, Middlesbrough: TS1 2RW Tel: 01642 249300 / Fax: 01642 249600 email: [email protected] Registration form for voluntary and community organisations/groups About your organisation (Please place an 'x' against any information you do not wish to be publicly accessible) Organisation Main contact Name Name Job title Address Address (if different from organisation) Postcode (if Postcode different from organisation) Tel: (if different Tel: from organisation) Fax Email (if different Email from organisation) Minicom Website Legal status (Tick all that Registered Type of organisation (Tick all apply) no: that apply) Community Interest Branch of national voluntary Company organisation Company Limited by Development Trust Guarantee Constituted Other (please specify) organisation/group Industrial and Self help/service-user led group Provident Society Other (please Social enterprise specify) Unconstituted community group Registered Charity or club 1 April 2010 Geographical area covered. Premises Yes/No Please tick appropriate box(es) Does your organisation Acklam own/lease premises out? Ayresome Beckfield Do you have rooms Beechwood available for hire (We may contact you at a later date Brookfield for further information). Clairville Coulby Newham Gresham Hemlington Kader Ladgate Your main users/beneficiaries. Linthorpe Choose up to 3 numbering 1-3 Marton (1 being primary Marton West user/beneficiary) Middlehaven Asian/Asian British (incl. Indian, North Ormesby & Brambles Farm Pakistani) Nunthorpe Black & ethnic minority (all) Pallister Black/Black British (incl. African, Park Caribbean) Park End Carers Children aged 0-11 Stainton & Thornton Disabled people (general Thorntree category) University East & South East Asian (incl. All of Middlesbrough Chinese, Filipino) North East Region East European Economically disadvantaged Tees Valley people Wider Families/parents Gay/lesbian/bisexual people Homeless people Size of organisation (this Lone parents Offenders/ex-offenders information will not be made Older people public) People of faith Annual turnover People with learning disabilities People with long-term/chronic Under £1,000 illness £1,000 - £4,999 People with mental health needs £5,000 - £9,999 People with physical disability £10,000 - £49,999 People with sensory impairment £50,000 - £99,999 Refugees/people seeking asylum Substance misusers £100,000 - £249,999 Survivors of abuse £250,000 - £499,999 Tenants and residents £500,000 - £1 Million Transgender people Over £1 Million Travellers Unknown Unemployed people Number of volunteers Victims of crime (including management Women committee) Young people aged 11-25 Number of paid staff Other (please specify) 2 April 2010 Organisation's main purpose. Employment/training Choose up to 3, numbering 1-3 Environment/conservation/ heritage (1 being primary purpose) Faith/religion Accommodation, housing & Family services homelessness Funding and grant making Accountancy/financial services Health and well-being Act as umbrella or resource Inclusion & integration body Infrastructure support Advice/information services International aid Advocacy Listening service Animal welfare Mediation Arts/media/culture Mental health support Befriending Mentoring Business support Mobility services Campaigning Peer support/self help Carers services Research Childcare Sexual abuse services Community development Social and community care Community facilities & Social and recreational buildings activities Community safety/crime Sports/leisure/recreation reduction Substance misuse Counselling and therapy services Transport Day care Volunteering Domestic abuse services Youth services Education Other (please specify) Brief description of the aims and activities of your organisation, as you would like it to appear (Maximum 50 words). Data Protection The information you have given will be placed on the directory of local voluntary and community organisations, which eventually will be accessible to the public through MVDA's website, with appropriate links developed to increase its visibility. If there is any information you do not wish to be publicly accessible please indicate by placing an ‘x’ against it. Please sign below to confirm you wish to be included. Name (please print) Signed Role in organisation Date 3 April 2010 Information and publications All organisations are routinely included in our general mailing list to receive newsletters etc, please indicate with an ‘X’ if you do not want to be included. Sign up for MVDA's themed circulations. Please indicate which categories of information you would like to receive and give, amend or confirm details of the appropriate contact for each, within your organisation Interest Groups: Chair (of the governing body, this cannot be a paid employee of the organisation) (CH) Chief Officers (the most senior paid officer in the organisation, who is directly responsible to the governing body) (CO) Children & young people (C&YP) Economic Development & Enterprise (incl. training & employment) (EDE) Health & social care (H&SC) Housing related support (HRS) Safer Communities (SC) General funding opportunities (non-targeted) (FUND) Interest Name Job title Address Postcode Phone Email group 4 April 2010 .