Your name (required):
If you are concerned about this you can either give us your real name or another name. Whatever you choose, the name you enter will be used when we communicate with you.

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* 1. Your name (required):
If you are concerned about this you can either give us your real name or another name. Whatever you choose, the name you enter will be used when we communicate with you.

Your postcode (required)
We need the first 4 or 5 digits of your postcode, then the following digit eg BS4 4 or BS16 5

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* 2. Your postcode (required)
We need the first 4 or 5 digits of your postcode, then the following digit eg BS4 4 or BS16 5

Your month of birth (required):

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* 3. Your month of birth (required):

Your year of birth (required):

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* 4. Your year of birth (required):

Your email address (required):

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* 5. Your email address (required):

If you would prefer us to contact you by post please provide your address:

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* 6. If you would prefer us to contact you by post please provide your address:

If you would like us to contact you by text please provide your telephone number:

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* 7. If you would like us to contact you by text please provide your telephone number:

How did you hear about the Voice and Influence Partnership?

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* 8. How did you hear about the Voice and Influence Partnership?

Please describe your ethnicity:

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* 9. Please describe your ethnicity:

Do you consider yourself to be a disabled person?

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* 10. Do you consider yourself to be a disabled person?

It helps us to know whether we are reaching include all types of disability. Please can you tick the relevant impairment (disability) group below:
Please tick all the boxes that apply.

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* 11. It helps us to know whether we are reaching include all types of disability. Please can you tick the relevant impairment (disability) group below:
Please tick all the boxes that apply.

What is your religion?

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* 12. What is your religion?

Do you identify as:

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* 13. Do you identify as:

Do you identify as the sex assigned at birth?

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* 14. Do you identify as the sex assigned at birth?

Do you identify as:

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* 15. Do you identify as:

I give consent to share my contact details with the following Voice and Influence partners as I would like to start (or continue) to receive news and updates from them:
Please tick all the boxes that apply.

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* 16. I give consent to share my contact details with the following Voice and Influence partners as I would like to start (or continue) to receive news and updates from them:
Please tick all the boxes that apply.

By completing this form I give consent to The Care Forum to store my data and send me information about the project and local consultations.

The Care Forum will use demographic data to provide ANONYMOUS statistical reports to Bristol City Council about who completed consultations.

I understand my personal identifiable data will only be shared with organisations I ticked in question 15. It will not be shared with any other party.

I understand The Care Forum will store my data for the period of the project or will be deleted at any time should I request it.

To read the Voice and Influence Partnership Data Privacy statement please go to www.thecareforum.org/wp-content/uploads/2018/07/here.pdf
Finally please rate the following statements with a score from 1 to 5, where 1 = not at all and 5 = totally agree.

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* 17. Finally please rate the following statements with a score from 1 to 5, where 1 = not at all and 5 = totally agree.

Voice and Influence Partnership (VIP) aims to reduce disadvantage and inequality by amplifying your voice and enhancing the influence you can have.

For information about the work of the project or about how you can become a volunteer:

VIPadmin@thecareforum.org.uk
www.thecareforum.org/voice-influence-partnership/


0117 965 4444
Voice and Influence Partnership, C/O The Care Forum, Vassall Centre, Gill Avenue, Fishponds, BS16 2QQ

Voice and Influence is a partnership delivered by The Care Forum, LGBT Bristol, Bristol Older People's Forum and Bristol Multi Faith Forum and is advised by Sari, Bristol BME Voice and WECIL.

Voice and Influence Partnership is funded by Bristol City Council.



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