Haringey Council

1. Personal Information

Title

First name *

Last name *

Date of birth *

DD MM YYYY

What best describes your gender? ('Prefer to self describe' option can be found in the next tab)

Please enter your postcode and click Get Address

Home address *

Town or City

County

Postcode *

Country

Mobile

Email *

If English is not your first language please state what your first language is

Please describe your ethnic origin (for Greek\Turkish Cypriots or Kurds select 'White - other' and select your ethnicity in the 'Ethnicities - further information' section.
For ethnicities not in the list select the closest category to you and add your text in the in the 'Ethnicities - further information' section.)

What is your religion? (if other please specifiy)

Do you have any dependants? (If yes, please specify the number of dependants under the age of 18)

Would you need an interpreter (including a British sign language interpreter) if you were going to attend a face to face meeting?

Are you a member of Haringey Council staff?

2. Additional Information

Would you like to self describe your gender?

Yes

Do you have any long term health conditions? (Mental or Physical health conditions that last longer than 12 months)
If Yes then do any of your illnesses or conditions reduce your ability to carry out day to day activities?

Yes

Prefer not to say

Yes, limited a lot

Yes, limited a little

Do you look after or give any help or support to family members, friends, neighbours or others because of either long-term physical or mental ill-health or disability, or problems related to old age?

Ethnicities - further information

Greek\Greek Cypriot

Turkish\Turkish Cypriot

Kurdish

Other white background (please specify)

Other mixed background (please specify)

Other asian background (please specify)

Other black background (please specify)

Other ethnic background (please specify)

3. Review

Last Used Services

Title

First name

Last name

Date of birth

What best describes your gender? ('Prefer to self describe' option can be found in the next tab)

Address

County

Postcode

Country

Mobile

If English is not your first language please state what your first language is

What is your religion? (if other please specifiy)

Do you have any dependants? (If yes, please specify the number of dependants under the age of 18)

Would you need an interpreter (including a British sign language interpreter) if you were going to attend a face to face meeting?

Are you a member of Haringey Council staff?

Would you like to self describe your gender?

Do you look after or give any help or support to family members, friends, neighbours or others because of either long-term physical or mental ill-health or disability, or problems related to old age?

Ethnicities - further information

4. Finish

* The personal information you supply on this form will be used to include you in Citizens’ Panel activity, such as online surveys, telephone interviews and workshops. Our recruitment partner Civica collects and stores this information on our behalf; besides Civica, we will not share your information with any third parties. The information you provide via this application form and through panel activity will be stored in accordance with the current Data Protection Act. Please see Civica's Privacy Notice, and Haringey Council's Privacy Notice. You can withdraw your permission if you change your mind at any point. Otherwise, we will retain the information for the duration of the Panel.

To agree to the above and become a member of Haringey's Citizens’ Panel, please tick the box alongside this text.

The Public Sector Equality Duty does not expressly require the council to collect equality information. However, collecting, analysing and using the information helps us to see how our policies and activities are affecting various sections of our communities. In employment and service provision, it helps us to identify any existing inequalities and where new inequalities may be developing and take action to tackle them. The council will gather the equalities monitoring information in a way that individuals will not be identifiable. In addition to the nine “protected characteristics” (Age, Disability, Gender Reassignment, Marriage and Civil Partnership, Sex, Race, Religion or Belief and Sexual Orientation) identified in the Equality Act 2010, we have added categories for Refugees and Asylum Seekers and Language in order to reflect the full diversity of Haringey. Civica Engagement Solutions fully adheres to the Data Protection Act 2018.

Further information about how Haringey Council manages the personal information that we hold relating to our residents, customers and service providers, is available on the Data Protection section of our website, and if you have any queries please contact our Data Protection Officer.

Click the Submit button below to become a Haringey Together Citizens’ Panel Member.