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First Name:	*
Last Name:	*
Organisation (if applicable):
House Number:	*
Street:	*
City:	*
County:
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Country:
Telephone:	*
Email:	*
Demographics
Age Group:		16–2526–4546–6060 or over
Ethnicity:
Sexual Orientation:		Do not wish to discloseLesbianGayBisexualHeterosexual
Marital Status:		MarriedCivil partnershipLiving togetherSingle
Involvement Level - I want to.....
Receive the LINk e-bulletin:
Participate in questionnaires and consultations:
Know about events and training opportunities:
Be involved in the LINk workgroups:
Receive the Steering Group minutes every month:
Help with mail-outs and distributing leaflets:
In what capacity will you be involved:		Individual VolunteerVolunteer for OrganisationPaid member of staff
Where did you hear about the LINk:		Health Centre/GPHospitalDay CentreNewsletter/LeafletSupport Worker/CarerEventOther
If Event or Other please specify:
Interested In
Interested in Social Care:
Interested in Primary Health Care:
Interested in Hospital Services:
Interested in Mental Health Services:
Interested in Ambulance Services:
Preferred method of receiving information:		Email Hard copy

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