BLF MEMBERS REGISTRATION FORM

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Thank you for taking interest in our Charity. Please use this form to register for access to all our FREE SERVICES. Find more here: www.bassuahlegacy.org/our-services

• Awareness & Social Events • Health & Wellness Programme • Basic Skills Programme • Employment & Volunteer Programme • General Support Service

Address: 90 Goldhawk Road, Shepherds Bush, London, W12 8HD

Phone No: +44 20 8834 4547 Hours: 12:00pm - 8:00pm (Closed on Tuesdays)

WhatsApp: +44 75 4475 7987 Registered Charity No: 1185562

Email *

Full Name *

Date of Birth *

Please enter the date of birth in this format DD/MM/YYYY eg: 30/06/1978

YYYY

Phone number *

Address *

Please enter your full address

Post Code *

Please enter your full post code

Ethnicity *

ASIAN: British, Indian, Pakistani, Bangladeshi or Any other Asian background || BLACK: African, British, Caribbean or Any other Black background. || MIXED: White and Black (African, Caribbean or Other), White and (Asian or Other), Black and Asian or Any other Mixed background || ORIENTAL: British, Chinese, Japanese or Any other Oriental background || WHITE: British, Irish, Scottish or Any other White background.

Asian

Black

Mixed

Oriental

White

Other:

Are you a single parent or from a single parent household? *

Are you currently a single parent or was your parent a single parent?

Yes

What best describes your current family structure? *

Single parent mother

Single parent father

Dependant of a single parent

Two parent family

Couple without children

Independent (Female)

Independent (Male)

How many children/dependants do you have? *

None

5 or more

What is your current employment status? *

Unemployed

Working 15 hours or less per week

Working 16 to 29 hours per week

Working 30 hours or more per week

Retired

What is your usual household income before tax, including working taxcredits and benefits? *

Less than 10,000

10,000 to 19,999

20,000 to 29,999

30,000 to 39,999

40,000 to 49,999

50,000 and over

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