Have Your Say!
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Thank you for your interest in joining 'Speak Now!', East Devons panel of local residents
Please fill in this form and submit your answers to us to become a member of the panel
Q1
   
Q2
   
Q3
   
Q4
   
We are asking the following three questions so that we can make sure a variety of people of different genders, ages and ethnic backgrounds are represented on the panel
Q5 Are you male or female?
 
 
Q6 What was your age on your last birthday?
PLEASE WRITE IN BOX BELOW
 
Q7
   
We are asking the following questions so that we can make sure we only send you questionnaires and invite you to discussion groups that are relevant to you e.g. if we want to find out about how disabled residents access our services we would invite disabled residents to comment
Q8 How many children aged 17 or under are living in your home as part of your household?
PLEASE TICK ONE BOX ONLY
 
 
     
Q9 Which of these activities best describes what you are doing at present?
PLEASE TICK ONE BOX ONLY
 
 
 
 
 
 
 
   
Q10 Do you have a long-standing illness, disability or infirmity? (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 ONE BOX ONLY
 
 
Q11 Does this illness or disability limit your activities in any way?
PLEASE TICK ONE BOX ONLY
 
   
 
Thank you very much for your information. All of your information will be kept only for the purposes of inviting you to have your say and will all be treated in accordance with the Data Protection Act 1998.
Please press on the Submit button to send us your form
We will be in touch with opportunities for you to get involved as they arise
If you have any queries or if at any time you would like to remove yourself from the 'Speak Now' panel please contact us on (01395) 517569 or e-mail jbuckley@eastdevon.gov.uk
 
    Link to http://www.snapsurveys.com/