Equal Opportunities Form

Date of Birth

Gender SelectMaleFemalePrefer not to disclose

What is your nationality?

How would you describe your ethnic origin? * White - BritishWhite - Gyspy or Irish TravellerWhite - IrishWhite - RomaWhite - Any other White backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - Any other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - Any other Asian backgroundBlack or Black British - CaribbeanBlack or Black British - AfricanBlack or Black British - Any other Black backgroundOther Ethnic Groups - ArabAny other backgroundPrefer not to say

If other, please specify:

Are you disabled? Please selectYesNo

If yes, what is the nature of your disability?

If offered a volunteer role at St Luke’s, are there any specific requirements you have which will need to be facilitated? If so, what are they?

Name

Signed

Date

Email *