Membership Form Membership FormWakefield Care Association MEMBERSHIP FORM 2026/27 Fields marked with * are required.Care Business Name:Parent Company Name:Select Type of Service (tick all that apply) Care Home Care Home with Nursing Domiciliary Care Extra Care Supported Living Other community based serviceClient Group (tick all that apply) Over 65's Dementia Physical Disabilities Mental Health Under 65's Under 18's Sensory Impairment Learning Disabilities Palliative Care Drug and Alcohol DependenceCONTACT DETAILS (Provider Level – Director, Regional or Senior Manager)Contact Name 1Address Line 1TownPostcodeEmail AddressRoleAddress Line 2CountyTelephone NumberContact Name 2Address Line 1TownPostcodeEmail AddressRoleAddress Line 2CountyTelephone NumberCONTACT DETAILS (Registered Managers)Service/Care Home NameContact NameEmail AddressTelephoneINFORMATION REQUIRED – This information will remain confidential and will not be shared.Total Number of Beds: (If applicable)Total Number of Employees:Total Number of Hours of Home Care/Support Per Week: (If applicable)AUTHORISED SIGNATURESigned by:Position:DateBy joining as a member of Wakefield Care Association, you are agreeing to our privacy policy.Submit Form
