COVID-19 Community Information Campion Registration Form

COVID-19 Community Information Campion Registration Form

Covering the Welwyn Hatfield area
What is your name? *

First Name Last Name
What is your email address? *
example@example.com
Group Name / Organisation (if applicable)
Phone Number *
Please enter a valid phone number.

What is your preferred way of contact? *

Please select

Phone

No prefrence

Do you consider yourself to have a disability? *

Please select

Yes

Other

What is your gender? *

Please select

Male

Female

Other

What is your ethnic group? *
Do you consider yourself to represent any of these priority groups? *
How many people do you hope to reach? *
What is the type of community can you reach? eg Rural network, church group, friends, neighbours etc please specify *
What is the postcode for you or your community? *