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Details of Your Service or Organisation

Name or Title of Group / Organisation / Service / Supplier or other:

Named Contact:

Position:

Address:

Postcode:

Telephone:

Telephone direct line or extension number:

Fax:

Email:

Your Web Address:

Address of Contact (if different from above):

Details of nature of organisation (including aims, services provided, accessibility, activities, opening hours, age restrictions, etc.):

Venue for activities / service (if different from above):

Disability catered for:
Physical disabilities     Mental health problems     Visual impairment     Deafness     Communication difficulties     Learning difficulties

Age groups catered for:
Any age     Older people     Adults     Children

Please enter a specific age group (if appropriate):

Geographical area covered:
A nationwide service for everyone?     A service for everyone in West Sussex?     A local service only?

Please enter a specific geographical area:

Accessibility of premises/venue:
Level access throughout (no steps)     Wide doorways     Loop system     Lift     Ramps     Accessible toilets     Disabled parking bays

Do you provide leaflets, publications or factsheets:
Yes     No

Category of service:
Statutory organisation     Voluntary organisation     Registered charity     Independent/commercial organisation

Please complete this section.

Data Protection Act 1998

I am happy for this information to be used to facilitate access to information in West Sussex.

Name:

Date:

Part of the ICIS database may be available online. If this is the case, are you happy for the above details to be included, and made freely available on the Internet?
Yes     No

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