Cheshire East Local Involvement Network
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Tell us your experiences of local care services
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Telephone:
01606 45920
Email:
info@celink.org.uk
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Individual Membership Registration Form
Anybody with an interest in Health and Social Care can join the LINk. Please complete the information below to become a member.
To download a copy of this form, please click
here
Title (Mr, Mrs, Miss etc)
*
Surname
*
First Name
*
Address
Postcode
Telephone
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Email
How would you like to hear from us? (Please tick all that apply)
*
Post
Telephone
Email
How did you hear about the LINk?
To what extent would you like to be involved with the LINk?
Level 1
Level 2
Level 3
What do these levels mean?
What areas of health and social care are you interested in?
About you
We would be grateful if you would answer the following optional questions, which will help us ensure that the LINk is reaching all sections of the community.
Gender
-
Male
Female
Age Range
-
16 - 25
25 - 40
40 - 60
60 - 80
80+
Status
-
Employed
Unemployed
Student
Retired
Ethnic origin
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White British
Other White Background
Asian or Asian British
Black or Black British
Other
If other, please specify
Do you consider yourself to have a disability?
Yes
No
If yes, please give details
Do you have any specific needs or require a particular method of communication?
Would you also like to join Cheshire West and Chester LINK?
Yes
No
By clicking submit, below, you are agreeing to comply with the rules and code of conduct of the LINk (available
here
).
You are also agreeing to comply with the
terms and conditions of use.