Please provide a few details so we know a bit more about you and how to stay in touch. Providing a bit more information is optional, but will help us understand who is part of our network and who is missing.

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* 1. I want to join the Healthwatch North Yorkshire individual influencer network and consent to Healthwatch North Yorkshire storing and using my data. (See our privacy terms and conditions at: https://www.healthwatchnorthyorkshire.co.uk/privacy for more information)

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* 2. Your name

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* 3. Your contact details (how you want us to be in touch with you, eg email, phone, postal address)

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* 4. Where do you live? Choose the district that best represents where you are

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* 5. Which gender do you identify with?

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* 6. What is your age?

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* 8. Do you consider yourself to be a carer?

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* 9. Do you consider yourself to have a disability?

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* 10. Do you consider yourself to have a long term condition?

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