Sheffield Local Involvement Network

First Name  *

Surname  *

Address  *

Postcode  *

Preferred telephone number  *

Email

How would you to receive information from us? Post Email

Section B: Your Interests

Please tick to show which health and social care services you are particularly interested in.

Accident and Emergency Learning Disability Services Care Homes Mental Health Services Carers Older People’s Social Care Services Children’s Social Care Services Older People’s Health Services Dentists / Opticians Pharmaceutical Issues GPs Physical Disability Services Hospitals Specialist Services for Minority Groups If there is an area of interest not mentioned above, please add here:

We are always interested in hearing people's views on health and social care services in Sheffield. Do you have any particular comments or concerns about these services that you would like us to be aware of.

Section C: About You

To help us ensure we are gathering the views of a good cross-section of people, we need to know something about you.

This information is optional but any information you do give us will be kept in line with the Data Protection Act 1998 and only shared with your permission.

What is your date of birth?

What is your ethnicity? British White and Black Caribbean Chinese Irish White and Black African Somali East European White and Asian Yemeni Gypsy/Traveller Indian African Other Pakistani Caribbean Bangladeshi

Other

What religious belief do you have? Buddhist Jewish None Christian Muslim Other Hindu Sikh

Other

Do you consider yourself to have a physical disability? Yes No

Do you consider yourself to have a mental health issue?

If you have answered yes to either of these questions, please give us a little more detail:

Do you have any support needs that we should be aware of? For example receiving documents in large print or having an interpreter at meetings.

How did you hear about Sheffield LINk?

Section D: Terms & Conditions

Tick this box to become a member and agree to the following  *

• I agree to my details being added to Sheffield LINk's membership database so that Sheffield LINk can send me information about health and social care services
• I agree that my level of involvement in the work of Sheffield LINk is up to me
• I agree to the Code of Conduct for LINk members.
• I agree that I will notify Sheffield LINk as soon as possible if I wish to have my details changed or removed.

* Required field