Please complete the following - note that the information you provide is held by Archway in accordance with the Data Protection Act.

First Name *
Last Name *
Address 1
Address 2
Town City
Postcode
Telephone
Email *

About You - you do not have to complete the following, but it would help us if you did:

Would you describe yourself as:

Tenant

Home Owner

What is your gender:

Male

Female

Are you aged between:

Under 18

18 - 25

26 - 35

36 - 45

46 - 65

Over 65

Are you disabled:

Yes

No

Ethnic Origin: Please tick any categories which apply to you

White:

British

Irish

Other

Black/Black British:

Caribbean

African

Other

Mixed:

White & Black Caribbean

White & Black African

White & Asian

Other

Asian/Asian British:

Pakistani

Kashmiri

Bangladeshi

Indian

Other

Other Ethnic Groups:

Chinese

Gypsy Traveller

Other

Other, Please specify

Involvement in the Residents Network

Receive newsletter only & access to members page on the website (www.chapeltown.org)

Gret more involved with the network, receive surveys/questionnaires & be invited to meetings