Homepage | Join the Mailing list

You may wish to receive email communications from Draft Community Cohesion Strategy for North East Derbyshire 2009 to 2013 in the future. The form below will help you tell us about this.

All fields marked with * are required.

About you
* Please enter your forename:

* Please enter your surname:

* Please enter your postcode:


* Gender: Male   Female

* Date of birth (dd/mm/yyyy):

Ethnicity:

Do you consider yourself disabled? Yes   No

The definition of a disability in the Disability Discrimination Act 1995 is a physical or mental impairment which has substantial and long term effect on a person's ability to carry out normal day-to-day activities.

If 'Yes', it would be helpful if we had an understanding of your disability in order to ensure we provide an appropriate service to meet your needs. Please tick as appropriate:

Hearing Impairment
Vision Impairment
Mobility Impairment
Learning Difficulty
Long Term Condition

Other disability:

How and What we contact you about

Please check the interests that you would like to receive updates about:
Children and young people
Black and minority ethnic issues
Well-being
Health - general
Sport/Leisure
Planning
Jobs, careers and employment
Environment
Community and voluntary
Crime and community safety
Emergency planning
Older people
Housing
Homelessness
Traffic and Transportation
Business
Democracy and participation
Arts/Culture
Communication
Carers issues
Disability
Regeneration
Satisfaction
Social services/Care
Spending/Budget
Technology
Gender issues
Equalities
Environmental health/Consumer services
Benefits
Faith/Religion

* Please enter your email address:



* Data Protection Act 1998: The details you provide will be retained for as long as you remain subscribed with us, and from time to time we will let you know about future events, consultations and engagement activities which may be of interest to you. Do you agree to this? Yes   No

To unsubscribe please enter your email address:

Citizen Space is brought to you by Delib - the leading Consultation specialists