Focus group sign up Please complete this form to join our focus group looking at racial bias in health services for learning disabled children. Parent carers will be paid £50 for taking part in a focus group Remember to press the SUBMIT button at the end. Enter your details We will look after your details in accordance with our data protection policy. First Name Last Name Postcode Email Address Which focus group would you like to attend? Wednesday 20 April 10.30 - 12.30 Please tell us a bit about you and your child How old is your child/children? 0-5 6-13 14-18 19+ Does you child have a learning disability? Yes No Do you know what an Annual Health Check (AHC) is? Yes No Not sure Has your child ever had a Annual Health Check (AHC) at the GP? Yes No Not sure Your ethnicity: Please select Asian / Asian UK: Bangladeshi Asian / Asian UK: Chinese Asian / Asian UK: Indian Asian / Asian UK: Pakistani Asian / Asian UK: Any other Asian background Black / African / Caribbean / Black UK: African Black / African / Caribbean / Black UK: Caribbean Black / African / Caribbean / Black UK: Other background Mixed / multiple ethnicity: White & Asian Mixed / multiple ethnicity: White & Black African Mixed / multiple ethnicity: White & Black Caribbean Mixed / multiple ethnicity: Any other origin White: English / Scottish / Welsh / Northern Irish / UK White: Irish White: Gypsy or Irish Traveller White: Any other White background Other ethnic group: Arab Any Other Origin Prefer not to answer SUBMIT