Citizen's Panel Registration

Tamworth's Voice Citizen's Panel

Please note that questions marked * are mandatory. The equality monitoring questions are optional, however, letting us know a few details about you will assist us in ensuring that we gain a fair representation of Tamworth's population.


Name: *
Telephone Number:*
How would you like to be contacted with surveys?*	Email Post
Please provide either your postal address or email address below depending on how you would like to be contacted*
Ethnic origin: Asian or Asian British	Indian Pakistani Bangladeshi Other Asian
Other Asian, please state
Mixed Heritage	White and Asian White and Black African White and Black Caribean Other Mixed
Other Mixed , please state
Black or Black British	Black Caribbean Black African Other Black
Other Black, please state
White	British English Irish Scottish Welsh Other White
Other White, please state
Chinese or other ethnic group	Chinese Other mixed
Other mixed, please state
Prefer not to say	Prefer not to say
Do you consider yourself to have a disability or long term heath condition?	Yes No Prefer not to say
Gender:	Male Female Prefer not to say
Is your gender identity the same as the gender you were assigned at birth?	Yes No
Sexual orientation	Bi-sexual Heterosexual Gay man Gay woman/Lesbian Other Prefer not to say
Religion and Belief	Buddist Christian Hindu Jewish Muslim Sikh No Religion Prefer not to say Other
Other religion, please state
Age	18-24 25-34 35-44 45-54 55-64 65-74 75+ Prefer not to say
Submit

Personal Information given on this form will be added onto our Tamworth's Voice Citizen's Panel, and will not be disclosed to other parties without participants' consent.

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