Citizens Panel Registration

By completing this from you are agreeing to receive surveys on local issues sent by Bedford Borough Council and for you information to be processed in accordance with the privacy notice at the bottom of each page. Should you wish to be removed from the panel you can email citizenspanel@bedford.gov.uk at any time.

First Name

Surname

Contact Address

Postcode

Email Address

Please click 'Next' to continue

Citizens Panel Registration 2018

The following questions are not compulsory, and you are still welcome to join the panel if you choose not to answer them.

Gender (please tick one box only)
Male		Female		Prefer not to say

If female, are you currently pregnant? (please tick one box only)
Yes		No		Prefer not to say

Is your present gender the one you were assigned at birth? (please tick one box only)
Yes		No		Prefer not to say

Age (please tick one box only)
16 - 17		25 - 34		45 - 54		65 +
18 - 24		35 - 44		55 - 64		Prefer not to say

Please click 'Next' to continue

Citizens Panel Registration 2018

Do you have any of the following conditions? (please tick all that apply)
A physical disability		Learning difficulties		Prefer not to say
A sensory disability		Any other long term condition
Mental health problems		None of the above

What is your Ethnic Group? (please tick one box only)
WHITE English / Welsh/ Scottish / Northern Irish / British		MIXED Other
WHITE Irish		ASIAN Indian
WHITE Gypsy or Irish Traveller		ASIAN Pakistani
WHITE Other		ASIAN Bangladeshi
BLACK OR BLACK BRITISH Caribbean		CHINESE
BLACK OR BLACK BRITISH African		ASIAN Other
BLACK OR BLACK BRITISH Other		ARAB
MIXED White & Black Caribbean		OTHER
MIXED White & Black African		Prefer not to say
MIXED White & Asian

Please specify 'other' (please type in)

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Citizens Panel Registration 2018

Which of the following best describes your religion/faith or belief? (please tick one box only)
Buddhist		Jewish		No religion
Christian		Muslim		Other
Hindu		Sikh		Prefer not to say

Please specify 'other' (please type in)

Which of the following best describes your sexual orientation? (please tick one box only)
Bisexual		Gay woman / Lesbian		Other
Gay man		Heterosexual / Straight		Prefer not to say

Please click 'Submit' to send us your response