Applicant

First name *

Surname *

Postcode

Address *

Town/City

County

Postcode

Country

Preferred contact method *

Emails will be sent to the address below

Letters will be sent to the address above

Best time to phone

Email address

Phone

Mobile

Your date of birth *

Are there adjustments you require the council to make when communicating with you?

Yes

No

Please tell us what adjustments we can make for you e.g. large font, easy read version, different language, PDF or word document required.

About You

These questions are asked as part of our commitment to equalities monitoring and will help us to ensure that we are reaching a wide range of people with different backgrounds and experiences. The information that you give us will help us to make sure that everyone is treated fairly. We do not use it to identify individuals. Please answer as many questions as you feel comfortable with.

Your age *

How would you describe your ethnicity?

Are you:

Do you have a disability?

Yes

No

Prefer not to say

Preferred pronoun

Hearing impairment

Visual impairment

Mobility issues

Learning difficulty

Mental health condition

Physical impairment

Long standing illness or health condition

Social or communication impairment

Any other disability, impairment or medical condition

My Bay Scheme