The information you provide on this form will help us get our services right. As Panel Members it's important that we have these details so we can be certain about who we are in contact with and how your perspective will help us shape our services.  Particularly if we need views or input from specific groupings in our communities. So please answer the following questions, tick the appropriate boxes and include any extra information if necessary. We can't be expected to get our services right if we don't know who our customers are - so please tell us about who you are.  This information will remain confidential to the Council.

DATA PROTECTION NOTICE Babergh District Council is a Data Controller for the purposes of the Data Protection Act 1998.  Any personal information supplied on this form will be processed in accordance with the principles of the Act.  The details collected on this form will be used as part of an on-going public consultation exercise to help formulate policy and procedures.  Your information will not be used for any other purpose and your name or address will not be associated with any comments.

Name

Address:

Email:

Telephone:

Mobile Phone:

What is your Faith/Belief?
	Atheist
	Buddhist
	Christian
	Hindu
	Jewish
	Muslim
	None
	Pagan
	Sikh
	Any other (please give details below)

What is your Ethnic Origin?

White
	British
	Romany
	Irish
	Irish traveller
	Any other white background (please give details below).

Black or black British
	African
	Caribbean
	Any other black background (please give details below).

Bi-racial/dual heritage background
	White and Asian
	White and black African
	White and black Caribbean
	Any other mixed background (please give details below).

Asian or Asian British
	Bangladeshi
	Indian
	Pakistani
	Sri Lankan
	Any other Asian background (please give details below).

Chinese
	Chinese
	Any other Chinese background (please give details below).

What is your Age?
	Under 16
	17 to 24
	25 to 39
	40 to 49
	50 to 59
	60 to 74
	75 to 84
	85 and over

What is your Gender?
	Female
	Male
	Transgender
	Living as the sex opposite to that shown on your birth certificate.

What is your Sexuality?
	Heterosexual (Straight)
	Homosexual/Gay Man
	Lesbian/Gay Woman
	Bisexual

Do you consider yourself to have a physical disability or impairment that has a substantial effect on your ability to carry out normal day-to-day activities?
	Yes
	No

If Yes, please provide details:

Do you consider yourself to have a mental disability or impairment that has a substantial effect on your ability to carry out normal day-to-day activities?
	Yes
	No

If Yes, please provide details:

Household Details - Do you:
	Live alone
	Live with partner
	Live with relatives
	Live with friends
	Live with people dependant on you or your partner
	Any other combination - please give details below

Please provide details:

Do you have dependant children?
	Yes
	No

If Yes, how many:

Employment details:
	Employed - Full-time
	Employed - Part-time
	Unemployed
	Retired
	Full-time Education
	Home Carer
	Self-employed
	Other

If Other, please provide details:

Are there any other details about your life that could have a bearing on the services you need from the Council e.g. do you care for a dependant relative?

How would you like us to contact you?
	By email
	By letter

Thank you for joining our Panel.   We will confirm your registration/send you a welcome pack shortly. The Fairness and Equal Access Group Babergh District Council Corks Lane Hadleigh IPSWICH IP7 6SJ Telephone:  01473 826672

Once complete, click on the "Submit" button below.  You should then receive confirmation that your submission was successful.  Should you encounter any problems with your submission please contact a member of the Support Services Team, Democratic and Support Services Section, Telephone: 01473 825727 Thank you.