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

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Your First Name

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

We would like to know a little more about you. The following questions will help us understand who has joined our network and help to ensure we are engaging with a wide section of the community. It also helps us make sure that the surveys that we send you are relevant and useful.

Please provide your full postcode

What is your religion?

No religion

Christian (including Church of England, Catholic, Protestant and all other Christian denominations)

Buddhist

Hindu

Jewish

Muslim

Sikh

Any other religion (please specify)

Prefer not to say

Comments:

This is required

How do you describe your gender identity?

Male

Female

Trans-Man

Trans-Woman

Non-binary

Gender-non-conforming

Prefer not to say

Other (please specify):

This is required

What is your sexual orientation?

Heterosexual/ Straight

Lesbian

Gay

Bisexual

Asexual

Prefer not to say

Other (please specify):

This is required

What is your relationship status?

Married

Civil Partnership

Single

Divorced

Lives with Partner

Separated

Widowed

Prefer not to say

Other (please specify):

This is required

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

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)

This is required

Comments:

This is required

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

Yes

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

Prefer not to say

Have you ever served in the armed services?

Yes, at present

Yes, previously

Prefer not to say

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

Yes

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

Your First Name

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

Please provide your full postcode

What is your ethnic group?

How old are you?

What is your religion?

How do you describe your gender identity?

What is your sexual orientation?

What is your relationship status?

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?

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).

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

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.)

Have you ever served in the armed services?

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

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Your First Name

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

Please provide your full postcode

What is your ethnic group?

How old are you?

What is your religion?

How do you describe your gender identity?

What is your sexual orientation?

What is your relationship status?

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?

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).

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

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.)

Have you ever served in the armed services?

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

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.)