Local Membership Form By joining as a local member your organisation will be given a page on the DAA’s website www.dementiaaction.org.uk, which links to your local alliance page (if one exists in your area). If you are completing this form on a computer, please click on the relevant boxes to fill them in and save the document to one of your files. You can then email it to Please also send us your organisation’s logo (if possible by e-mail in .jpg format) it will be – displayed on your page along with your Action Plan. Organisation name _________________________________________________ Our commitment: Our organisation agrees to sign up to the National Dementia Declaration - and commits to our action plan below: Contact Details Contact name and Click here to enter text. role Address here to enter text. Phone Click here to enter text. Email Click here to enter text. Website Click here to enter text. Can we share your contact details with other Dementia Action Alliance members? ☐ ☐ Yes No Organisation type - please tick the relevant words that best reflect your organisation ☐ Arts ☐ ☐ Pharmaceutical ☐ Transport Health Care Public sector Utility ☐ ☐ ☐ Hospitality ☐ Communication Recreation Voluntary ☐ ☐ ☐ Medical ☐ ☐ Emergency Services ☐ Research ☐ Other ☐ Membership ☐ Finance ☐ Retail Organisation summary - Please tell us briefly (up to 150 words) what your organisation does: Local Alliance – Please tell us what local alliance you would like to join or the area you cover if one does not exist:
Local Membership Form By joining as a local member your organisation will be given a page on the DAA’s website www.dementiaaction.org.uk, which links to your local alliance page (if one exists in your area). If you are completing this form on a computer, please click on the relevant boxes to fill them in and save the document to one of your files. You can then email it to Please also send us your organisation’s logo (if possible by e-mail in .jpg format) – it will be displayed on your page along with your Action Plan. Organisation name _________________________________________________ Our commitment: Our organisation agrees to sign up to the National Dementia Declaration - and commits to our action plan below: Contact Details Contact name and role Click here to enter text. Address here to enter text. Phone Click here to enter text. Email Click here to enter text. Website Click here to enter text. Can we share your contact details with other Dementia Action Alliance members? Yes ☐ No ☐ Organisation type - please tick the relevant words that best reflect your organisation ☐ Arts ☐ Care ☐ Communication ☐ Emergency Services ☐ Finance ☐ Health ☐ Hospitality ☐ Medical ☐ Membership ☐ Pharmaceutical ☐ Public sector ☐ Recreation ☐ Research ☐ Retail ☐ Transport ☐ Utility ☐ Voluntary ☐ Other Organisation summary - Please tell us briefly (up to 150 words) what your organisation does: Local Alliance – Please tell us what local alliance you would like to join or the area you cover if one does not exist:
DAA-Local-Membership-Form_090614-1.docx