Viewpoint membership form 2014

Viewpoint Citizen Panel - Membership Application Form

Thank you for your interest in joining South Gloucestershire Council's Viewpoint Citizen Panel. Please read the instructions for answering each question carefully. If you have any questions or would prefer a print version of this form, please contact viewpoint@southglos.gov.uk.

Name

Title

First name

Surname

Address (please note only current residents of South Gloucestershire can join the panel)

House number

Flat number

Building name

Street

Town

Postcode

Contact details

Q10

Telephone

Q11	Email address (This is our preferred method of communication. If you supply an email address, you will receive surveys by email.)

Q12

We may occasionally organise focus groups to speak to our residents directly and hear their thoughts on certain topics. If you would be interested in being invited to our group sessions, please tick the box below. There is no obligation to attend.

Yes, please invite me to focus groups.

Personal details

We aim to reflect the population of South Gloucestershire's population and communities on the panel. To allow us to monitor if we are successfully doing this, please provide the following details about yourself. Anonymous information may also be used to analyse survey data to see how the views of our residents vary based on things like age and gender.

Q13

Are you a Council Member or employed directly by South Gloucestershire Council (SGC)?

Yes (please do not continue)

Q14

Are you..?

Male

Female

Prefer not to say

Q15

What is your date of birth? (DD/MM/YY)

Q16	If you would prefer not to give us your date of birth, please indicate which age band you fit into. (Please note children under 16 cannot join the panel.)

Q17

Which of the following apply to your household? (please tick all that apply)

Single person household under 65

Two person household under 65

Family with children over 18

Single person household over 65

Two person household over 65

Multi-generational household

Shared house

Family with children under 18

Other

If other, please specify:

Q18

Do you consider yourself to be disabled?

Prefer not to say

Yes - Physical impairment, such as difficulty using arms or mobility issues which may mean using a wheelchair or crutches

Yes - Sensory impairment, such as being blind/having a serious visual impairment or being deaf/having a serious hearing impairment

Yes - Mental health condition, such as depression, anxiety or schizophrenia

Yes - Dementia or memory loss

Yes - Learning disability/difficulty (such as Down's Syndrome, dyslexia, dyspraxia) or cognitive impairment (such as autistic spectrum disorder)

Yes - Long-standing illness or health condition, such as cancer, HIV, diabetes, chronic heart disease or epilepsy

Yes - Other

If other, please specify:

Q19	Please tell us your ethnic origin:

Data Protection Statement

The information you provide will be used to contact you to take part in the surveys and consultation work of the citizens panel of South Gloucestershire Council and to compare survey data between different groups of citizens. All personal information that you have supplied will be stored securely and held by South Gloucestershire Council in accordance with the Data Protection Act. The information you have supplied will not be used to identify individuals. Your personal data will not be published or shared with any other organisations or individuals unless required by law. Anonymous data and reports from the citizen panel's surveys and consultation work may be shared with the public and the council's partners and may be published on the council's website.

Q21	Please state your name below to say that you accept the data protection statement and to confirm the accuracy of the information you have provided.

Please note: Panel members may leave the panel at any time by contacting viewpoint@southglos.gov.uk. The panel may be refreshed on a regular basis to allow other residents to take part. South Gloucestershire Council reserves the right to remove members from the panel for refreshment purposes and to decline membership applications if a certain demographic group is over-represented on the panel.

Thank you for your interest in joining the Viewpoint Citizens panel. Please press the submit button below to send us your application.