Apply for our HemiHelp focus group Please complete this expression of interest form for our focus group for families living with hemiplegia on either Monday 13 or Wednesday 15 June. We’re asking you to complete a few questions below. We only have 10 spaces, and we would like to consult with parents with a range of experiences and backgrounds. Please remember to press the SUBMIT button at the end. We will confirm places on Thursday 9 June. Thank you for your time. We will look after your details in accordance with our data protection policy. Please note that we will be recording the session, but this will only be used to help us take notes and will be deleted after use. The views you share with us will be used anonymously to help us improve our services. First Name Last Name Postcode Email Address Telephone Number Do you have a child with hemiplegia? Yes No How old is your child? 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 Any additional information it might be relevant for us to know to ensure the session is accessible for you. When would you prefer the session to take place? 12.30-2.30pm, Tuesday 19 July 10am-12pm, Wednesday 20 July Submit