Title

First name*

Surname*

Contact address (home or office)*

Postcode

Telephone number*

Email address*

Part two - LINk involvement

Are you applying as a representative of a group or organisation? I will be representing: (name of group/ organisation) *

How would you like to be involved;
Active participant
Interest participant
Stakeholder participant

How would you prefer to receive regular information updates?
Post
Email

Are you interested in any particular services or issues?
General interest in health and social care matters
Cardiac Care
Children’s Services
Cleanliness & Infection Control
Diabetes
Direct Payments
Equipment
Food & Nutrition
Home Care
Maternity Services
Out of Hours Services – Health
Out of Hours Services – Social Care
Podiatry
Other (please state in the box below your interest)

Part three - Please tell us a little about yourself (this is optional)

Are you:
Male
Female

Date of birth (dd/mm/yyyy)

Your ethnic group or background

Are you a carer for someone who uses Cambridgeshire health or social care services? YES/NO
Yes
No

Do you consider yourself to have a disability? YES/NO
Yes
No

Is there anything else which would make being a Cambridgeshire LINk participant and attending LINk activities easier for you? This could include communication requirements such as large format documents, translation or a hearing loop system in meetings etc. Please let us know.

Part four - Privacy

Declaration: I want to become a participant of Cambridgeshire Local Involvement Network (LINk). I consent to the LINk Host, Cambridgeshire ACRE, to use this information in accordance with its privacy policy.

(*Mandatory fields)