West Yorkshire Voice - Individual Sign Up Form June 2024

Individual Membership

Welcome to West Yorkshire Voice. This is the form to join as an individual member which means representing your own views and/ or the views of someone you care for.

Please answer as many questions as possible, this makes it easier for us to link you to the best opportunities to be involved and to share your experiences and views.

You can also join as a group, to represent the experiences and views of those you support or work with.

The questions in bold must be completed to join

If you have any questions or need support completing the questions please contact:

To find out more:

Call 0113 898 0035
Call/ text 07496 403 341
info@westyorkshirehealthwatch.co.uk

Contact Details and About You

First Name (required)

Last Name (required)

Pronouns

Email (if you do not wish to receive emails/ don’t have access to an email, just write “no email”) (required)

Mobile Number (required)

How are you happy to receive information?

How are you happy to receive information? Email Post SMS Telephone

What year were you born? (required)

How do you describe your gender? (required)

Gender - Other Gender Description

Are you or have you ever been pregnant? (required)

What is your Marital Status? (required)

Do you consider yourself to be disabled? (required)

Which of the following describes you?

Which of the following describes you? Prefer not to say Physical or mobility impairment: (such as using a wheelchair, difficulty walking or using your hands) Hearing impairment: (such as being D / deaf or hard of hearing) Sight impairment: (such as being blind or partially sighted) Mental health condition: (such as having depression, schizophrenia, bipolar disorder) Learning, understanding, concentrating or memory: (such as Down's Syndrome, stroke, or head injury) Learning disability Neurodivergent condition: (such as autism, ADHD, dyslexia) Long term condition: (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy) Other

Disabled - Other Disability Description

Are you a carer? (required)

Are you a carer? (required) Prefer not to say I provide unpaid care or support for someone who is older, disabled or has a long-term condition Care for a child / children between 0 and 4 years old Care for a child / children between 5 and 9 years old Care for a child / children between 10 and 14 years old Care for a child / children between 15 and 19 years old None Secondary carer (another person carries out main caring role) Other

Caring Responsibilities - Other Caring Responsibilities Description

How would you decribe your ethnic group? (required)

Ethnic Group - Other Ethnic Group Description

If you require information in a different format, what format would you need? (required)

How would you describe your sexual orientation? (required)

Sexual Orientation - Other Sexual Orientation Description

What is your religion? (required)

Religion - Other Religion Description

How would you describe your employment status? (required)

Employment Status - Other Employment Status Description

Do you have any of the following health conditions or have an interest in? (tick all that apply) (required)

Do you have any of the following health conditions or have an interest in? (tick all that apply) (required) Acquired Brain injury Cancer Diabetes Digestive (e.g. Crohn's, IBS) Haematological (blood) (e.g. Sickle Cell) Heart Mental health Musculosketal (e.g. Fibromyalgia, Oestoporosis) Neurodivergent (e.g. Autism, ADHD) Neurological Parkinson's, Multiple Sclerosis, Stroke Respiratory conditions (e.g. Asthma, COPD) Sensory loss such as sight or hearing impairment Skin (e.g. Psoriasis)

Postcode (if you only want to receive information by post, please provide your full address) (required)

Please tell us what areas of health and care you are interested in? (tick all that apply) (required)

Please tell us what areas of health and care you are interested in? (tick all that apply) (required) Care in a hospital or other setting (e.g. outpatient clinic, hospital stay) Community services (e.g. physiotherapy, child health) First place you go when you need health advice or treatment (e.g. GP, Dentist, Pharmacy, Optician) Mental health Social care (e.g. supported living, care at home) Urgent and emergency care

How are you joining West Yorkshire Voice? (required)

How are you joining West Yorkshire Voice? (required) An individual representing my views An unpaid carer representing the views of someone I support