Brighton & Hove LINk, Sign-up to the LINk, 01273 810 235, Document, Social, _setaccount,

Step 1 of 4

01. Your Contact Details

Your title	Telephone Number
Your full name	Your Address
Organisation
Organisation
Email address	Your postcode
Your preferred method of contact Email Telephone Post
Your preferred format of contact Email Telephone Audio Symbols Braille Other (incl. different language) If other

Step 2 of 4

02. Your Interests

We understand that you may only be interested in certain aspects of health & social care. In order to receive information about and to be involved with the issues, please tick all that apply.

Children & young people	Primary Care (GPs, dentists, etc.)
Older People	Hospitals
Mental health & wellbeing	Long term conditions
Learning disability	Black minority ethnic communities
Sensory impairment	Drug / alcohol / substance misuse
Therapies (occupational etc.)	End of life care
Anything else

Step 3 of 4

03. About You

This information is collected so that we can monitor how well we represent local communities. Please complete as much information as you want to.
Age group Under 18 18-25 26-45 46-64 65+
How would you describe your ethnic background?
Do you consider yourself to have a disability? Yes No
Are you a carer? Yes No
I would describe myself as: Heterosexual Gay Lesbian Bisexual Transgender Prefer not to say
Type of involvement with the LINk? (Tick all that apply) Monthly newsletter (automatically sent) Surveys & polls Joining an action group relevant to my interests Other volunteering opportunities Enter & View (visiting health & social care premises) CRB check & further training required Help distribute LINk promotional materials

Step 4 of 4

04. Miscellaneous

Please use this space to describe any ideas or comments you have about health & social care in Brighton & Hove.

How did you find out about the LINk?

Poster	Leaflet	Newspaper / Newsletter
Friend / Family	Event
Other

Data Protection

The information on this form will be held on a database in accordance with the Data Protection Act 1998. We will use this information only to contact you about LINk activities.

I confirm that the information on this form is true. I agree to abide by the LINk's Code of Conduct. I agree that the LINk may hold and use information given on this form to enable my participation in the LINk.

Get Involved!

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Brighton & Hove's Independent Health & Social Care Watchdog

Tel. 01273 810 235

Sign-up to the LINk

01. Your Contact Details

02. Your Interests

03. About You

04. Miscellaneous

Health or Social Care

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