Sign up for the Shropshire, Telford and Wrekin People's Network

4. What is your ethnic group? *

White: English/Welsh/Scottish/Northern Irish/British
White: Irish
White: Gypsy or Irish Traveller
White: Any other White background (please specify below)
Mixed/Multiple ethnic groups: White and Black Caribbean
Mixed/Multiple ethnic groups: White and Black African
Mixed/Multiple ethnic groups: White and Asian
Mixed/Multiple ethnic groups: Any other Mixed/Multiple ethnic background (please specify below)
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Any other Asian background (please specify below)
Black/African/Caribbean/Black British: African
Black/African/Caribbean/Black British: Caribbean
Black/African/Caribbean/Black British: Any other Black/African/Caribbean background (please specify below)
Arab
Any other ethnic group (please specify below)
Prefer not to say

Comments:

5. How old are you? *

6. What is your religion? *

Comments:

7. How do you describe your gender identity? *

8. What is your sexual orientation? *

9. What is your relationship status? *

10. Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? *

Yes, limited a lot
Yes, limited a little
No

11. Do you consider yourself to have a disability? (The Equality Act 2010 states a person has a disability if they have a physical or mental impairment which has a long-term (12 month period or longer) or substantial adverse effects on their ability to carry out day-to-day activities). *

Physical disability (please describe)
Sensory disability e.g. Deaf, hard of hearing, Blind, visually impaired (please describe)
Mental health condition
Learning disability or difficulty
Long-term illness (please describe)
No / Prefer not to say
Prefer not to say
Yes - other (Please specify)

Comments:

12. Are you the parent or guardian of a child / children under the age of 18? *

Yes
No

13. Do you provide care for someone?

A carer is defined as anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support. (Tick as many as appropriate.) *

Yes - Care for young person(s) aged younger than 24 years of age
Yes - Care for adult(s) aged 25 to 49 years of age
Yes - Care for older person(s) aged over 50 years of age
No
Prefer not to say

14. Have you ever served in the armed services? *

Yes, at present
Yes, previously
No
Prefer not to say

15. I consent to receiving surveys and information on other engagement opportunities related to my membership of the People's Network

*

Yes
No

Sign up for the Shropshire, Telford and Wrekin People's Network

1. Your First Name *

2. Your Email Address (This will be our most common form of communication) *

3. Please provide your full postcode *

4. What is your ethnic group? *

5. How old are you? *

6. What is your religion? *

7. How do you describe your gender identity? *

8. What is your sexual orientation? *

9. What is your relationship status? *

10. Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? *

11. Do you consider yourself to have a disability? (The Equality Act 2010 states a person has a disability if they have a physical or mental impairment which has a long-term (12 month period or longer) or substantial adverse effects on their ability to carry out day-to-day activities). *

12. Are you the parent or guardian of a child / children under the age of 18? *

13. Do you provide care for someone?

A carer is defined as anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support. (Tick as many as appropriate.) *

14. Have you ever served in the armed services? *

15. I consent to receiving surveys and information on other engagement opportunities related to my membership of the People's Network

*

Sign up for the Shropshire, Telford and Wrekin People's Network

1. Your First Name *

2. Your Email Address (This will be our most common form of communication) *

3. Please provide your full postcode *

4. What is your ethnic group? *

5. How old are you? *

6. What is your religion? *

7. How do you describe your gender identity? *

8. What is your sexual orientation? *

9. What is your relationship status? *

10. Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? *

11. Do you consider yourself to have a disability? (The Equality Act 2010 states a person has a disability if they have a physical or mental impairment which has a long-term (12 month period or longer) or substantial adverse effects on their ability to carry out day-to-day activities). *

12. Are you the parent or guardian of a child / children under the age of 18? *

13. Do you provide care for someone? A carer is defined as anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support. (Tick as many as appropriate.) *

14. Have you ever served in the armed services? *

15. I consent to receiving surveys and information on other engagement opportunities related to my membership of the People's Network *

13. Do you provide care for someone?

A carer is defined as anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without their support. (Tick as many as appropriate.) *

15. I consent to receiving surveys and information on other engagement opportunities related to my membership of the People's Network

*