Welcome to the Citizens' Panel! If you would like to join the panel, please answer the following questions to tell us a little about yourself and how you would like to be contacted. All information will be treated in the strictest confidence.

Q1	Would you like to complete questionnaires online and be contacted by email or by post?
		Post		Email

Q2	Please provide your postal or email address of where you would like the surveys to be sent

Q3	Do you have any other comments about the Citizens' Panel Newsletter, for example how often you would like to receive it, what you would like it to contain

Q4	We are currently refreshing and updating the consultation section of the Wokingham Borough Council website. Is there anything which you would like to see on this?

Q5	Do you have any other comments about the Citizens' Panel or how we can improve access to services?

Personal Details

Q6	Name

Q7	Postcode

Q8	Age Range
		0 - 17 years		36 - 45 years
		18- 25 years		46 - 60 years
		26- 35 years		61 years and above

Q9	Do you consider yourself to have a disability or long standing illness?
		Yes		No		Prefer not to say

Q10	To which of these groups do you consider you belong?
		a) White (British, Irish, Traveller of Irish Heritage, Gypsy/Roma, any other white background)
		b) Mixed (White and Black Carribean, White and Black African, White and Asian, any other mixed background)
		c) Asian or Asian British (Indian, Pakistani, Bangladeshi, any other Asian background)
		d) Black or Black British (Caribbean, African or other Black background)
		e) Chinese
		f) Any other ethnic group, please state below
		Prefer not to answer

Other or other mixed

Q11	Which religious faith do you belong to?
		None
		Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
		Budhist
		Hindu
		Jewish
		Muslim
		Sikh

Other

Q12	Which ward do you live in? (Please leave blank if you are unsure)
		Arborfield		Hawkedon (Earley)		Sonning
		Barkham		Hillside (Earley)		South Lake (Woodley)
		Bulmershe & Whitegates (Woodley)		Hurst		Swallowfield
		Charvil		Loddon (Woodley)		Twyford
		Coronation (Woodley)		Maiden Erlegh (Earley)		Wescott (Wokingham)
		Emmbrook (Wokingham)		Norreys (Wokingham)		Winnersh
		Evendons (Wokingham)		Remenham, Wargrave & Ruscombe		Wokingham Without
		Finchampstead North		Shinfield North
		Finchampstead South		Shinfield South

Q13	Is there anything else that you would like to tell us about yourself?

Many thanks for completing this questionnaire