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Coventry Local Involvement Network
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Poll
On your most recent visit to UHCW - Walsgrave site how long did it take you to find a car parking space?:
Straight away
5-10 minutes
10-15 minutes
15-20 minutes
20-25 minutes
25-30 minutes
Over 30 minutes
I did not find a space
Events
Coventry LINk Steering Group Meeting - Tuesday 21st February 2012
(16 days)
Coventry LINk Steering Group Meeting - Tuesday 27th March 2012
(51 days)
more
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a. About you
Title:
*
Mrs
Miss
Ms
Mr
Dr
Prof.
Rev.
MP.
Your First Name:
*
Your Last name:
*
Gender:
*
Female
Male
Transgender
Are you registering as an Individual
Or are you registering as a member of voluntary/community group
Your organisations name (member of voluntary/community group):
b. Your Contact details
Address:
*
post code:
*
Telephone number (best contact number):
*
Mobile:
When is the best time to contact you:
c. Carers
Are you a carer:
--
Yes
No
People who care for other people are important to LINk - whether the care informally (e.g.a friend or relative), as a volunteer or in a paid capacity.
Please give details:
d. Completing this section will help us check that we are including a wide range of people from across Coventry
White British
White Irish
Traveler/Romany
Eastern European
Other White:
Asian or Asian British
Indian
Pakistani
Other Asian:
Black or Black British
Caribean
African
Other Black:
Mixed: White and Black caribean
Mixed: White and Black African
Mixed: White and Asian
Other Mixed heritage:
Chinese
Other ethnic group:
e. Disability
Do you consider yourself to be disabled?:
*
No
Yes
f. Please Indicate your age
Age:
*
Under 16
16-24
25-34
35-44
45-54
55-64
65-74
over 74
g. Are you interested in - Community Health Services
GPs and health centres
Out of hours service
Dentistry
Opticians
Occupational therapy and specialist equipment
Health visiting service
Drug and alcohol services
h. Are you interested in - Hospital services
Inpatient
Outpatient
Accident and emergency
Maternity
i. Are you interested in - Adult social care services
Residential Care
Day care
Help at home
Respite care
j. Are you interested in - Mental health services
Inpatient services
Community mental health services
Services for people with learning disabilities
k. Ambulance services and patient Transport
Interested in ambulance services and patient transport
l. other areas
Any other health or social care service or group of service users:
m. Get involved
I would like to recieve information from Coventry LINk about the areas of interest expressed above
I would like the opportunity to feed in my views about the areas I have expressed an interest in
I would like to volunteer on a working group doing practical work to look at services
I would like to volunteer as a LINk Community Outreach Volunteer
I would like to Volunteer for election to the LINk governing group
How much time could you volunteer a month:
Please send me LINk information by::
*
Email
Post
Please tell us if you have any communication requirements, e.g. Braille, Large print etc.:
Account information
Username:
*
Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.
E-mail address:
*
A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.
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