SECTION 1 | This information will be published in the SHQ Online Directory 1. Group Details Fullname of Self Help or Support Group Acronym (if any) Membership Fee (if any) (eg: per year, per meeting, gold coin, etc) 2. Contact Details Phone 1 Phone 2 Mobile Freecall TTY Fax Address (for publication) State PostCode Email 1 Email 2 Website Facebook Would you like your address to be displayed on a Google map on the directory listing? Yes No (Not advisable if this is a home address.) 3. Group Description Description Please briefly describe the purpose of your group. Who can join? eg. Anyone, women only, men only, sufferers, carers, interested others, etc. What area does your group service? eg. Statewide, National, Regional Areas, Specific Suburbs, Postcodes, etc. Contact Hours eg. 24 hours, Monday – Friday, 9 am – 5 pm, Tuesday and Thursday only. Please ring at a reasonable time, etc. Services/Activities e.g. Phone Support, Email & Online Support, Meetings (weekly, monthly, biannual etc), Internet Chat Room, Newsletter, Information Kits, Fact Sheets, Library, Peer Support, Guest Speakers, Hospital Visits, Seminars, Workshops, Friendship, Social Outings, Court Support, Personal or Other Advocacy, Social Action, etc. Please list specific diseases, issues etc (if applicable) that your group caters for eg. A Family Abuse Support group might include words such as Domestic Violence, Physical Abuse, Sexual Abuse, Emotional Abuse etc. eg. A mitochondrial Disease Support Group might include people affected by Alpers Syndrome, Barth Syndrome, Lactic Acidosis, Luft Disease, Leighs Disease etc. 4. Search Facilities Please list the key words you think people would use to search for your group. Use as many words as you wish eg. Grief and loss, suicide, depression, genetic, bereavement, mental health, intersex, chronic illness, diabetes, asthma, Rett Syndrome, Fibromyalgia, Parenting, GLBTI etc Other information Any other information/stipulations your group particularly wants people to know about before they make contact with you. 5. Authorisation Please note that you must be authorized to post this information on behalf of the group. Your Full Name Date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Please check (☒) to authorize Self Help Queensland to include the above information in the SHQ Online Directory. SECTION 2 | Not for Public View (SHQ internal use only) 6. Contact Information Name (Preferred contact for group) Position Preferred Phone no Preferred Email Address SECTION 3 | Free Newsletter Subscription) Please support SHQ and the environment by receiving our free quarterly newsletter by email. Please choose (☒) your preference below. Email Postal Address Group does not want to receive the SHQ Newsletter If there is not enough room on this form please feel free to add a separate page/s or your group’ brochure. By submitting this form, you accept the Mollom privacy policy.
