Pot Dogs monitoring form

This programme is supported by the National Heritage Lottery Fund using National Lottery funds. The project is being run by 104 projects CIC.
POT DOGS PARTICIPANT FORM
Section 1: Participant Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityPostal/ Zip Code

Telephone Number
Email
example@example.com
Section 2: Supporting Statement
Can you tell us a few words about your experience on the programme?
Section 3: Terms and Conditions
Your submission of this form to us will constitute your confirmation of the following declaration:
- By submitting this form, I understand that 104 films and National Lottery Heritage Fund will store and process my data as described below in accordance with professional standards and data protection legislation.
- I confirm that I am over 18.
Data Protection
In order for you to be able to participate in Pot Dogs, 104 projects needs to be able to process your personal data.
- Part or all of the information you give 104 projects will be provided to NLHF.
- 104 projects will retain this information following your participation in the Pot Dogs programme for statistical purposes only.
Section 4: Diversity and Inclusion monitoring form
104 projects CIC wish to ensure that all aspects of our work reflect diversity and support equality of opportunity. Therefore, we would like to take this opportunity to ask you to complete an equality monitoring form.

This monitoring information helps us to identify where there are gaps in our recruitment so that we can work to attract talented people from these groups and areas. It also helps us to ensure that there is no discrimination.

Your cooperation in completing this form is greatly appreciated.

Any information you provide us with will be used for equalities monitoring purposes only. We use this information to produce anonymised statistical data on equalities, which we may publish and share with the organisations providing our funding.

Please note you will need to return this form as part of your application, providing any of the information requested is optional.
Gender
Please state your gender

MaleFemaleOtherPrefer not to say
Is the gender indicated the same as your gender at birth?
Ethnicity
Please tell us your ethnic origin

Asian/ British - IndianAsian / British - PakistaniAsian/ British - BangladeshiAsian / British - ChineseAny other Asian OriginBlack / British - AfricanBlack / British - CaribbeanAny other Black OriginWhite - British (English/Welsh/Scottish or Northern Irish)White - IrishWhite - Gypsy or Irish TravellerAny other white backgroundMixed ethnic origin - White and Black CaribbeanMixed ethnic origin - White and Black AfricanMixed ethnic origin - White and AsianAny other mixed ethnic group
Disability: The Equal Act 2010

The Equality Act 2010 defines disability as a 'physical or mental impairment which has a substantial long term effect on a person's ability to carry out normal day to day activities'
Do you consider yourself to have a disability? 104 films actively encourage applications from disabled participants, including those with non-visible disabilities and mental health issues.

YesNoNon-visible disabilityMental health issuesPrefer not to say
Socioeconomic Background
Have you ever been in care? That is, looked after by the state.

Yes, I am currently in careYes, I was previously in careNo, I have not been in carePrefer not to say
Thank you for completing this application form.

Please click submit and we will get back to you shortly
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POT DOGS PARTICIPANT FORM

Section 1: Participant Information

Section 2: Supporting Statement

Section 3: Terms and Conditions

Data Protection

Section 4: Diversity and Inclusion monitoring form

Gender

Ethnicity

Disability: The Equal Act 2010

Socioeconomic Background