Registration
First Name:
Last Name:
Username:
E-mail:
Password:
Verify Password:
Address 1:
Address 2:
Address 3:
City / County:
Post Code:
Telephone:
Are you a user of health and/or social care services:	Yes No
Are you a carer for someone who uses health and/or social care services:	Yes No
Are you a senior manager (third tier and above) in the statutory or private sector providing Health / Social Care or Housing Services in the London Borough of Ealing?:	Yes No
Are you registering an interest in the LINk on behalf of an organisation or group:	Yes No
Your organisation name (if applicable):
Is your organisation:	Statutory Voluntary Private
Does your organisation represent Minority Ethnic Communities:	Yes No
How would you prefer to receive information and updates about the LINk:	Email Telephone Text Post Mobile
Are you interested in any particular services or issues:	Adult social care services or issues Hospital services or issues for adults or children Mental health services or issues Primary care services or issues for adults or children(GPs, Community nursing, dentists, pharmacists, optometrist etc) Sheltered Housing Supported Housing Housing Options for vulnerable people Learning disability services or issues Older People services or issues Disability services or issues Carers’ services or issues Health and social care issues in neighbouring boroughs
MONITORING FORM
Sex:	Male Female
Age:	16 - 21 30 - 44 60 - 74 22 - 29 45 - 59 75 +
Do you consider yourself to have a disability:	Yes No Declined to answer
Would you define yourself as:	Heterosexual Bi-sexual Gay Other Lesbian Declined to answer
What religion do you define yourself as:	None Muslim Buddhist Hindu Christian Declined to answer Sikh Jewish Other religion
How would you describe your ethnic background:	White British Mixed – White & Asian Black or Black British – African White Irish Asian or Asian British – Indian Black or Black British – Other White Other Asian or Asian British – Pakistani Chinese Mixed – White & Black Caribbean Asian or Asian British – Bangladeshi Other Mixed – Other Asian or Asian British – Other Declined to answer Mixed – White & Black African Black or Black British – Caribbean
Subscribe to:	LINk Newsletter Select newsletters format: Receive newsletters:   as emails formatted in HTML    as plain text emails
Interested in:	Helping to establish and shape the LINk Registering to become involved in the LINk I would like to find out more about standing for election to the LINk decision-making body I would like to become a volunteer for the LINk (e.g. helping with LINk administration, newsletters etc.) I would like to receive training to become an authorised person to take part in official inspections of health and social care premisesof health and social care premises I would like to be kept informed about what is happening with the LINk