Medway is committed to consulting with all its residents and so, to ensure that all groups within the community have the opportunity to participate in this consultation, we would appreciate it if you could provide us with the following information. The information provided will remain private and confidential and will not be used for any other purpose. You are under no obligation to provide the following information and it will not affect your input if you choose not to. |
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Are you? (please tick one box only) |
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In which of the following age bands do you fall? (please tick the appropriate box) |
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Do you have any long-standing health problem or disability? Long-standing means anything that has lasted, or is expected to last, at least 12 months. (please tick the appropriate box)
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If yes, what is the nature of your health problem or disability? (please tick the appropriate box) |
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What is your ethnic group? |
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In which area do you live? (Please tick one box only) |
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