Newlands and Savannah Data Collection Form

This survey is for the Newlands and Savannah residents to enable your representative to serve you better and keep you informed on all our community activities. We would appreciate all residents over 18 completing it. Please note that this information will not be shared with any outside entities and will be used strictly for the improvement of our communities. Thank you!

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* 1. First Name

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* 2. Last Name

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* 3. Constituency

Newlands

Savannah

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* 4. Home Phone #

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* 5. Mobile Phone #

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* 6. Date of Birth

Date / Time

Date

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* 7. P.O. Box

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* 8. KY1-

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* 9. Street Address

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* 10. Email

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* 11. Are you currently employed?

Yes

No

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* 12. Employer

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* 13. Are you currently looking for work?

Yes

No

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* 14. If you are unemployed, please tell us what qualifications or experience you have.

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* 15. How many children are you parent or guardian for and live in your household (aged 17 or younger only)?

None

1

2

3

4

More than 4

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* 16. Please provide NAME, AGE and DATE OF BIRTH for all children in the house 17 and under.

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8

Child 9

Child 10

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* 17. Would you like to receive community newsletters via email?

Yes

No