Key Customer Registration Form

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Involvement Works
The Significant Seven
Annual Customer Conference
Key Customer Panel
FASA
Midland Network
Customer Involvement Calendar
Customer Groups
Customer Satisfaction Surveys

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Friendship Care and Housing, 50 Newhall Hill, Birmingham, B1 3JN

Tel: 0300 123 1745


Title*
First Name*
Last Name*
Address*
Postcode*
Telephone Number*
Mobile Number
Email Address
Gender*	Male Female
Date of Birth
Are you......*	A general tenant A leaseholder A care service user Other (please state)
Other:
Do you consider yourself to have a disability?*	Yes No
If yes, Please give details:
Why do you want to get involved? (Tick all that apply)*	To help improve services To learn new skills To learn about how Friendship is run To get personal housing issues resolved To make new friends Just for something to do Other (please state)
Other:
When is best for you to get involved? (Please Tick)*
How would you like to get involved? Please tick.*	Key Customer Panel FASA Quality Inspectors 3C’s Improvement Panel Customer Involvement Working Group Walkabouts Service Improvement Monitoring Panel Contract Monitors Local customer groups Mystery Shopping Opportunities in Property Services Telephone and postal surveys Editorial Board Key Customer Conference Committee E-mail and Text message polls Opportunities in Housing Management Board of Management Any
Have you any special requirements for attending meetings and events that we can help with? (such as mobility issues or dietary requirements etc)
For equality and monitoring purposes please tick the box that best describes you.	White British White Irish Caribbean African Indian Pakistani Bangladeshi White & Caribbean White & Black African White & Asian Chinese Other (please state)
Other:
Sexual orientation (please tick)	Heterosexual (straight) Gay Lesbian Bi-sexual Do not wish to state