Your Application to join the Hinckley & Bosworth Citizens Panel

Name

Mr / Mrs / Ms / Miss /Other

……………………………………………………………………………………..…

Address………………………………………………………………………………

………………………………………………………Postcode………………

Preferred E-mail address………………………………………………………

Telephone Number/s Home……………………… Mobile…………………

(Please note if you do not include either an e-mail address or telephone number we will be unable to invite you to events / focus groups)

Gender

Are you male or female?

Please tick one box

Male
Female

Age

Year of birth?

Health, illness and disability

Do you have any of the following long-standing conditions? (Please include problems which are due to old age). Please tick all boxes that apply.

Deafness or severe hearing impairment
Blindness or severe visual impairment
A learning difficulty
A condition that substantially limits one or more basic physical activities such as walking, climbing stairs, lifting or carrying
A long-standing psychological or emotional condition
Other, including any long-standing illness
No, I do not have a long-standing condition

Does a long-standing health problem or disability mean you have substantial difficulties doing day-to-day activities?

Please include problems which are due to old age.

YES
NO

Do you consider yourself to have a disability?

YES
NO

Ethnicity, Identity and Religion

What is your ethnic group? Please choose one section from (a) to (e) and then tick one box only to show your ethnic group.

A. White
English
Other British
Irish
Black background
Any other White background
B. Mixed Group
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
C. Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
D. Black or Black British
Caribbean
African
Any other
E. Other Ethnic
Arab
Gypsy/Romany/Irish Traveller
Any other

What is your religion? Please tick one box only

None
Christian (all denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other religion

What is your employment status? Please tick one box only

Employed
Unemployed
Self Employed
Homemaker
Retired
Student

Housing, do you? Please tick one box only

Own your own home
Rent (council)
Rent (Private)
Rent (Housing Association)
Other

Would you like future questionnaires in another format?

If yes please state what......

Please be assured that all information provided is for statistical purposes only and will be treated in the strictest confidence in accordance with the Data Protection Act.

Please return completed application to:

Cal Bellavia

Citizens Panel

FREE POST Licence No FPN5717

Hinckley & Bosworth Borough Council

Hinckley Hub

Rugby Road

Hinckley

Leicestershire

LE10 0FR