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* 1. Name

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* 2. Membership number (if you know it)

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* 3. Mobile number

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* 4. Email address

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* 5. Preferred communication method (tick all that apply):

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* 6. Do you have any of the following conditions? Please tick all the boxes which apply to you:

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* 7. We are looking to create safe spaces for members with protected characteristics: which of the following would you find useful?

  Yes No
WhatsApp group
In-person meeting
Virtual meeting

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* 8. Please use this space to note any comments you would like to make.

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