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If you do not have access to email, please call 020 7358 7005
Title* - select - Mr Mrs Miss Ms Dr Prof Mast
First Name*
Last Name*
Address*
Postcode*
Contact phone number*
Mobile number
Community Council area* - select - Bermondsey Borough and Bankside Camberwell Dulwich Nunhead and Peckham Rye Peckham Rotherhithe Walworth Dont Know
I am interested in being involved in LINk Southwark as*
An individual
A representative of a group or organisation
If registering as a group, please state the name of your group
I am particularly interested in services and issues about:
Social Care
Mental Health
Hospitals
GPs
General Health Care
Something affecting my local community
Other
I would like to be involved in LINk Southwark by:
Helping plan and prioritise the work of LINk Southwark
Helping practically (like serving refreshments or delivering notices around the community)
Being in a task group about a specific issue or service
Attending meetings and answering questions about LINk Southwark
Being kept informed by email
LINk Southwark is working towards ensuring its members are representative of the community it serves. To help us to do this, we need to monitor the background of its members. Please could you help us to do this by completing the form below. The information you give is in confidence. It will be used only for statistical purposes to monitor the operation of LINk Southwark.
Gender
Male
Female
Ethnicity/Racial Group
White
White British
Irish
Black or Black British
Black Caribbean
Black African
Mixed
White and Black Caribbean
White and Black African
White and Asian
Chinese or Middle Eastern
Chinese
Middle Eastern
Asian or Asian British
Indian
Pakistani
Bangladeshi
Do you consider yourself to have a disability
Yes
No
If yes, please advise how we can assist you.
Do you consider yourself to be:
Heterosexual
Lesbian
Gay
Bisexual
Transgender
Please indicate which age group you are in:
Under 16
16-25
26-35
36-45
46-55
56-65
66+
Employment status:
Full/part-time employed
In full-time education
Unemployed and seeking work
Out of work due to sickness/disability
Looking after home or family
We will store all LINk Southwark information securely and will never pass any of your personal details to any other organisation.
Upon receipt of registration, we will send you a member’s information pack.
I would like to become a member of LINk Southwark
I would like to receive emails from LINk Southwark
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