Our Youth Forum

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If you’re under 18, please ask a parent or guardian to complete this with you as we will need their details and permission to get in touch.

Your name

First name

Last name

The name of your parent or guardian (if you are under 18).

First name

Last name

Email

Phone

Relationship to Evelina London

I am a current or previous patientI live in Lambeth or Southwark

About you

I am a patient aged:

Under 1010-1414-18

Tell us why you are interested in becoming a member of the Evelina London Youth Forum. Please use this space to tell us a little about yourself. How do you think you might help us improve services?

Do you have any special dietary requirements?

YesNo

If yes, please describe below

Please let us know about any other support or assistance you may need

Help us to understand the community we serve

The next three questions are completely optional - you do not need to answer them to complete the form. However, thank you if you choose to answer them, as we want to check we are reaching all parts of our community.

Your ethnic background (please tick one box)

WhiteAsian or Asian BritishBlack or Black BritishChinese or other ethnic groupMixedPrefer not to say

Religion

ChristianBuddhistHinduJewishMuslimSikhOtherPrefer not to say

Do you consider yourself to have a disability?

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Age

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Our Youth Forum

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