This form is under test. Click here to see the current, live version. Entries with a yellow background are required. About you Name: Address: Postcode: Email address: Phone number: Please tick which of the following best describes you:I have had PPI am a husband/partnerI am a family member/friendI am a health professional/studentI am a researcher/academicI am a journalist/work in the mediaI am considering pregnancy/pregnant with an increased risk of PPI am an APP supporterOther: Big Lottery questions We are required to ask some questions by our funders, the Big Lottery, for equality monitoring purposes please don’t be put off by these quite personal questions – feel free to tick the ‘Prefer not to answer this question’ option if you want to. What is your date of birth? What is your gender?FemaleMale Do you consider yourself to be disabled as set out under the Equality Act 2010?YesNoPrefer not to answer this question NB. The Equality Act 2010 defines a disabled person as someone who has a mental or physical impairment that has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities Which of these ethnic groups do you consider you belong to?English/Scottish/Welsh/Northern Irish//UKIrishGypsy or Irish travellerAny other white backgroundIndianPakistaniBangladeshiChineseAny other asian backgroundAfricanCaribbeanAny other Black/African/Caribbean backgroundArabMixed ethnic backgroundOther ethnic groupPrefer not to answer this question What is your religion or belief?No religionChristian,BuddhistHinduJewishMuslimSikhOther religionPrefer not to answer this question What is your sexual orientation?Towards someone of the same sexTowards someone of a different sexTowards someone of the same sex and the opposite sexPrefer not to answer this question APP Network volunteering If you are interested in volunteering with APP, tell us the kind of things you would be interested in getting involved in:FundraisingSupporting people affected by PPRaising awarenessTelling my storyBeing a local representative for APP (see below)Taking part in researchOther: NB. Being a local representative for APP involves raising PP awareness, campaigning, fundraising and offering support in your local area.