CONFIDENTIAL

MONITORING INFORMATION (OPTIONAL)

Gloucestershire Local Involvement Network (LINk)

DATA PROTECTION

The personal details you choose to provide will be held by Gloucestershire Rural Community Council on behalf of the Gloucestershire Local Involvement Network (LINk) and will not be passed onto any third party or used for any purpose other than involving you in the LINk, without your permission.

This information helps the LINk to monitor how representative of the community it is.  It will be separated from the registration form on receipt.

1. GENDER

Male

Female

Transgender: Is your gender identity the same as your gender at birth?

Yes

No

2. AGE GROUP
16-24
25-34
35-44
45-54
55-64
65-74
75+

3. ETHNICITY

Asian - Bangladeshi

Asian - Indian

Asian - Pakistani

Black or Black British - African

Black or Black British - Caribbean

Chinese

Mixed - White & Asian

Mixed - White & Black African

Mixed - White & Black Caribbean

White - British

White - European

Other ........................................................................

4. DISABILITY

Do you consider yourself to have a disability?

Yes

No

5. RELIGION

Which of the following best describes your religion/belief?

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

No religion

Other

6. SEXUAL ORIENTATION

Do you consider yourself to be?

Bisexual

Gay

Heterosexual

Lesbian