Active Citizensapplication Form

Active CitizensApplication Form

We have a limited number of places on this course. If we have more people than places, we will use the information on this form to select who takes part. The Active Citizens programme is designed for people who want to make change happen in their community, and to give them the communication and project management skills to do so. If you need help filling out this form, please call Up Our Street on 0117 954 2834.

Name
Address
Date of Birth
Email
Phone

Can you tell us a bit more about yourself? This could be work, education or volunteering experience.

Why would you like to take part in the Active Citizens programme?

Equalities monitoring
Gender
Female / Male / Transgender / Prefer not to answer
Sexuality
Bisexual / Heterosexual / Lesbian or Gay / Prefer not to answer
Disability
No / Yes / Prefer not to answer
Faith
Buddhist / Christian (including Church of England, Catholic, Protestant and all other Christian denomination)
Hindu / Jewish / Muslim / No religion
Sikh / Any other religion, please describe / Prefer not to answer
Ethnicity - Choose one option that best describes your ethnic group or background
White - English/Welsh/Scottish/Northern Irish/British / Gypsy or Irish Traveller / Irish / Prefer not to answer
Any other White background, please describe
Mixed/multiple ethnic groups - / White and Asian / White and Black African / White and Black Caribbean
Any other Mixed/multiple background, please describe
Asian/Asian British / Bangladeshi / Chinese / Indian
Pakistani / Any other Asian background, please describe
Black/African/Caribbean/Black British / African / Caribbean
Any other Black/African/Caribbean background, please describe
Other ethnic group / Arab
Any other ethnic group, please describe
Employment Status
Full time / Part time / Student / Prefer not to answer
Self employed / Retired / No (can't) / No (looking)

Data protection

Your contact details will be added to our database in accordance with the Data Protection Act 1998. You will receive mailings from Up Our Street only – we will never pass your details to a third party without your permission. You can unsubscribe at any time by contacting us.

The information you provide on this form is confidential and will only be used to select participants for the Active Citizens programme.

Please return this form to or to the Up Our Street office at The Beacon Centre, Russell Town Avenue, Bristol BS5 9JH