Future Whipps: join our Community Engagement Action Group

Community Action Group Application Form

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* 1. Title

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* 2. First name

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* 3. Preferred name if different

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* 4. Last name

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* 5. Date of Birth

Date / Time

Date

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* 6. What is your address?

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* 7. Contact number

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* 8. How would you prefer to be contacted and when is the best time?

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* 9. Please tell us why you would like to become a community connector and Community Engagement Action Group member

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* 10. Please explain how you feel your skills and experience/knowledge are relevant to the role

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* 11. How did you hear about the role?

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* 12. Interviews will be informal and last roughly 30-40 minutes. Please indicate your preferred interview date:

Monday 11 February 2019 between 6 and 9pm

Wednesday 13 February 2019 between 1.30 and 4.30pm