Registration Form

• Ward Please select ward Addiscombe East Addiscombe West Bensham Manor Broad Green Coulsdon Town Crystal Palace & Upper Norwood Fairfield Kenley New Addington North New Addington South Norbury & Pollards Hill Norbury Park Old Coulsdon Park Hill & Whitgift Purley & Woodcote Purley Oaks & Riddlesdown Sanderstead Selhurst Selsdon & Addington Village Selsdon Vale & Forestdale Shirley North Shirley South South Croydon South Norwood Thornton Heath Waddon West Thornton Woodside Other (Outside Croydon) Outside of Croydon (Under LBC Care)

• Benefits Please select benefits Disability Allowance/ ESA Housing Benefit Income Support JSA - Job Seekers Allowance Not applicable UC - Universal Credit Working Tax Credits Unknown / Unspecified
• Gender Please select gender Female Male Transgender Gender Neutral Other Prefer not to say
• Ethnicity Please select ethnicity Asian / Asian British - Indian Asian / Asian British - Pakistani Asian / Asian British - Bangladeshi Asian / Asian British - Other Black / Black British – Caribbean Black / Black British – African Black / Black British - Other White – British White – Irish White – European White – Other Mixed Background - White/Black Mixed Background - White/Asian Mixed Background - Other Other – Chinese Other – Arab Other – Other Unspecified Prefer not to say
• Age Please select age 0 - 18 19 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+ Prefer not to say
• Religion Please select religion Christian Jewish Muslim Hindu Buddhist Sikh None Other Prefer not to say
• Educational Level Please select educational level 01. None 02. Level 1 or Equivalent 03. Level 2 or Equivalent (GCSE) 04. Level 3 or Equivalent (A Levels) 05. Level 4 or Equivalent (CERT HE) 06. Level 5 or Equivalent (Foundation Degree) 07. Level 6 or Equivalent (Bachelors Degree) 08. Level 7 or equivalent (Masters Degree) 09. Level 8 or equivalent (PHD)
• Convictions Please select convictions None Spent Unspent TBC/Unsure
• ID Type Please select id type Birth Certificate UK Driving Licence UK - Full Driving Licence UK - Provisional Passport - UK Passport - EU Proof of NI Residence Permit Unspecified / TBC NO ID

• • Disability / Illness
  • Please select disability / illness Yes No Prefer not to say
• • Blind/ sight loss
• • Learning disability
• • Progressive condition
• • Mobility
• • Manual dexterity
• • Deaf or hearing loss
• • Mental illness
• • Cardiovascular conditions
• • Speech impairment
• • Cognitive disability
• • Epilepsy

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