Title
Miss Mr Mrs Ms Dr Lady Lord Rev Sir
First name(s)

Surname

Email

Telephone number

Address

Postcode

I am happy to be consulted in the following ways (please tick all that apply)

Telephone Email Focus Group discussion meeting

So that we can make sure that we treat everyone fairly, the Council records the race, gender and disability of its customers. Because of this and for no other reason, you are asked to answer the following questions. You do not need to complete them.

Male Female

Do you consider yourself to have a disability?
Yes No

If yes, do you require any special assistance with access to our services?
Yes No

If yes, tell us what you need below

I would describe my ethnic origin as:

White British White Irish Other White White and Black African White and Black Carribean White and Asian Other Mixed Pakistani Indian Bangladeshi Other Asian Black Carribean Black African Other Black Chinese Other