Charnwood Borough Council's Citizens' Panel Application Form If you would like to join our Citizens' Panel please provide us with the following details. We will use this information for three purposes: 1. Your contact details will be used to involve you in consultations. 2. The information about your gender,age,ethnicity etc... will be used to help us to make sure our members represent all section of Charnwood's community. 3. Your areas of interest will be used to identify which issues you would most like to be consulted about. Personal Information Your Name: Your Current Address: (including postcode) Current Telephone Number: Current E-Mail Address: Date of Birth: Gender:   Male Female To which of these groups do you consider you belong to? Please tick üone box only   White British White Irish Any other White Background (ü and write in below) Mixed White & Black Caribbean Mixed White & Black African Mixed White & Asian Any other Mixed Background (üand write in below) Chinese Black or Black British Caribbean Black or Black British African Any other Black or Black British Background (ü and write in below) Asian Indian Asian Pakistani Asian Bangladeshi Any other Asian background (ü and write in below) Other (ü and write in below) Do you have any long standing illness(es), disability(ies) or infirmity(ies)? (long standing means anything that has troubled you over a period of time or that is likely to affect you over a period of time). Please tick üone box only   Yes No Please state the nature of the illness / disability Please tick ü all appropriate boxes.   Physical impairment (such as using a wheelchair to get around and/or difficulty using arms) Sensory impairment (such as being blind or deaf) Mental health conditions (such as depression, schizophrenia) Learning disability (such as Down's syndrome or dyslexia) Cognitive impairment ( such as autism or head injury) Long-standing illness or health condition (such as cancer, HIV, diabetes, chronic heart disease or epilepsy) Other (Please tick ü and write in below) Would this illness or disability limit your ability to take part in any of our consultations? (e.g. completing questionnaires, attending meetings) Please tick üone box only   Yes No If yes, please let us know what we can do to make your participation easier? (e.g. questionnaires in large print, holding meetings in your local community) What is your current work status? Please tick ü one box only.   Employee in full time job (30 hours or more per week) Employee in part time job (less than 30 hours per week) Self employed (full or part time) Government supported training Unemployed and available for work Retired from work Full-time education at school, college or university Looking after family / home Doing something else (Please tick ü and write in below) Are you a Council tenant? Please tick üone box only   Yes No Areas of Interest Which of the following council services are you interested in? Please tick üas many boxes as apply   Benefits Service Council Tax Services Waste Collection (e.g. recycling, household rubbish collection, litter) Planning Environmental Health Licensing (e.g licenses for public houses) Community Safety (e.g crime and anti-social behaviour) Parks and Open Spaces Leisure Centres Theatres and Museums Council Housing Community Grants Regeneration Markets and Fairs Other (please write below) What local Charnwood issues are most important to you? (please write in the box below) How do you want to be consulted? As a member of the Citizens' Panel you will be asked to complete a number of paper based questionnaires each year. We may also wish to consult you using the following methods. Please let us know which of these types of consultation you would be interested in taking part in: Please tick üas many boxes as apply   Telephone Surveys Discussion Groups (e.g. workshops, focus groups, meetings etc...) Online Polls (via E-Mail, internet) Other (if there are other types of consultation you would like to take part in, please write below) Are there any other types of consultation not listed above that you would you to be involved in? Thank you for this information

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