About you First name Enter your first name Last name Tell us your last name Type of membership Are you an individual living ,working or with another connection to Coventry Are you A representative from a voluntary or community group covering Coventry or part of Coventry Please name the group Email address Enter your email address here Address Post code Telephone number Please tell us you gender Female Male Non binary Prefer not to say Prefer to self descibe Are you a family / informal carer? - None -YesNo Prefer not to say Do you consider yourself to be disabled? - None -YesNoPrefer not to say Please tell us your age group - None -16-1718-2425-4950-6465-7980+ years Prefer not to say Please select your ethnicity to help us ensure we are including different communities within Coventry - None -ArabAsian / Asian British: BangladeshiAsian / Asian British: ChineseAsian / Asian British: IndianAsian / Asian British: PakistaniAsian / Asian British: Any other Asian / Asian British background (please specify)Black / Black British: AfricanBlack / Black British: CaribbeanBlack / Black British: Any other Black / Black British background (please specify)Mixed / Multiple ethnic groups: Asian and WhiteMixed / Multiple ethnic groups: Black African and WhiteMixed / Multiple ethnic groups: Black Caribbean and WhiteMixed / Multiple ethnic groups: Any other Mixed / Multiple ethnic groups background (please specify)White: British / English / Northern Irish / Scottish / WelshWhite: IrishWhite: Gypsy, Traveller, or Irish TravellerWhite: RomaWhite: Any other White background (please specify)Any other ethnic group (please specify) If other, please describe your ethnicity Interests Please select all the areas which interest you All areas GP and other community based services Hospital services Mental health services Learning disability services Support to stay well and healthy Services for long term health conditions Children's social care services Adult social care services Support for family carers Other service – please say below Involvement with Healthwatch Coventry Please tell us a little more about how you would like to be involved Receive information and the option to be involved in surveys and meetings or events Find out more about volunteering Please tick all that apply Communication needs We will send out information by email unless you need information in a different way Do you have any communication need? Yes No Please tell us about your communication need How we use your information We will not pass on your information or data to third parties outside of Healthwatch Coventry without your permission. You can ask Healthwatch to delete your membership information at any time. Find out more about how we safeguard and use information here. If Voluntary Action Coventry stops running Healthwatch Coventry we will write to you with your options before passing your contact details to the new organisation. I confirm that the information given on this form is true and I agree to my information being held on the databases and paper files for the purposes of Healthwatch Coventry. Consent I confirm that the information given is true and agree to it being held by Healthwatch Coventry. Sign up Leave this field blank
