Member type	Community Colleagues Young People's Network
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Capt Wing Commander Col Major Commodore Cllr Sister Master Lady Mayor
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For environmental/cost reasons, we will use email as the preferred method of contact with you unless requested otherwise
Preferred method of contact	Email Post
Monitoring Information
We want to ensure our membership is accessible to all. The information requested below will be valuable in helping us to identify any inequalities or gaps
Ethnic Origin	Asian or Asian British Black or Black British Mixed of Multiple Ethnic Origins White Any other ethnic group I prefer not to say
Do you consider yourself to be?	Not Stated Heterosexual/Straight (opposite sex) Gay/Lesbian (same sex) Bisexual (more than one sex) Prefer not to say Other
Do you identify as:	Female Male Transgender Prefer not to say

Do you have any special postal requirements	Large print No email address
Do you have a health problem or disability that limits your day to day activity	No Yes Prefer not to say Yes, limited a lot Yes, limited a little
How would you like to be involved?	Receive regular news updates and information Receive invitations to member events Join discussion and focus groups Join our Readers Panel to review patient literature Help to recruit new members at community events Take part in colleague recruitment panels Consider standing for election to the Members' Council Become a Locala volunteer
Please select any services that you are interested in	Breastfeeding support Calderdale GP practices Care home support Children’s community nursing Community COPD service (chronic obstructive pulmonary disease) Community matrons Community rehabilitation Continence advisory service Contraception and sexual health Day surgery Dementia Dental Dermatology District nursing End of life care Family nurse partnership Health visiting Immunisation service Intermediate care Locala walk-in Centre Palliative care Podiatry Rapid response service School nursing Service for people with diabetes Service for people with heart problems Smoking cessation Speech and language therapy TB nursing (tuberculosis)
How are you connected with Locala?	Patient Carer of a patient Previously worked for Locala Student Volunteer Colleague Member of the Young People’s Network
How did you hear about Locala?	At a community event Locala website Newspaper Radio Through a friend/family member Through a Locala colleague School/College

Member type
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Are you:
Address
County
Postcode
Mobile
Email
Ethnic Origin
Do you consider yourself to be?
Do you identify as:
Do you have any special postal requirements
Preferred method of contact
Do you have a health problem or disability that limits your day to day activity
How would you like to be involved?
Please select any services that you are interested in
How are you connected with Locala?
How did you hear about Locala?

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