Become a Change Maker We are so pleased that you've decided to become one of Contact's Change Makers. Please fill in this form so that we can learn a little more about you. We will look after your details in accordance with our data protection policy. Remember to press SUBMIT at the end. Enter your details First Name Last Name Postcode Email Address Telephone Number I give my permission to be contacted about the Change Maker programme and for my data to be processed as outlined in the privacy policy. Yes No Please tell us a bit about you Please tell us a bit about your family (eg what would you like to speak out on) Where do they live in UK? Please select England - East of England England - London England - South East England - South West England - West Midlands England - East Midlands England - Yorkshire and Humber England - North East England - North West Northern Ireland Scotland Wales 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 Have done a TV or radio interview before? Yes No Have you ever had support from Contact (eg used our helpline, website, event) Yes No Not sure What are you hoping to get out of joining Contact Change Makers? About your children The next question asks about your child's age and diagnosis, if they have one, and any additional information about your child’s needs or diagnoses, if you wish. If you have more than one disabled child, you can complete the questions for two additional children. If not, simply skip to the end of the form and press submit. Child 1 The year of birth of your first child who is disabled or has additional needs Please select 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 Primary diagnosis or condition Please select Attention Deficit Hyperactivity Disorder (ADHD) Autism Spectrum Conditions Cerebral palsy Downs syndrome Hearing impairment Heart condition Hemiplegia Learning disability Physical disability Rare condition Social, emotional and mental health Speech, language and communication needs Undiagnosed Visual impairment Other Prefer not to say Primary additional need, if relevant Please select Allergies Asthma Chronic or long term pain Complex health needs Diabetes Dyslexia Dyspraxia Epilepsy Hearing impairment Hypermobility Incontinence Learning disability Life-limiting or life-threatening condition Lung conditions Physical disability Profound and Multiple Learning Difficulty Sensory needs Social, emotional and mental health Speech, language and communication needs Visual impairment Additional diagnosis or need, if relevant Please select Attention Deficit Hyperactivity Disorder (ADHD) Allergies Asthma Autism Spectrum Conditions Cerebral palsy Chronic or long term pain Complex health needs Diabetes Downs syndrome Dyslexia Dyspraxia Epilepsy Hearing impairment Heart condition Hemiplegia Hypermobility Incontinence Learning disability Life-limiting or life-threatening condition Lung conditions Physical disability Profound and Multiple Learning Difficulty Rare condition Sensory needs Social, emotional and mental health Speech, language and communication needs Visual impairment Other Child 2 The year of birth of your second child who is disabled or has additional needs Please select 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 Primary diagnosis or condition Please select Attention Deficit Hyperactivity Disorder (ADHD) Autism Spectrum Conditions Cerebral palsy Downs syndrome Hearing impairment Heart condition Hemiplegia Learning disability Physical disability Rare condition Social, emotional and mental health Speech, language and communication needs Undiagnosed Visual impairment Other Prefer not to say Primary additional need, if relevant Please select Allergies Asthma Chronic or long term pain Complex health needs Diabetes Dyslexia Dyspraxia Epilepsy Hearing impairment Hypermobility Incontinence Learning disability Life-limiting or life-threatening condition Lung conditions Physical disability Profound and Multiple Learning Difficulty Sensory needs Social, emotional and mental health Speech, language and communication needs Visual impairment Additional diagnosis or need, if relevant Please select Attention Deficit Hyperactivity Disorder (ADHD) Allergies Asthma Autism Spectrum Conditions Cerebral palsy Chronic or long term pain Complex health needs Diabetes Downs syndrome Dyslexia Dyspraxia Epilepsy Hearing impairment Heart condition Hemiplegia Hypermobility Incontinence Learning disability Life-limiting or life-threatening condition Lung conditions Physical disability Profound and Multiple Learning Difficulty Rare condition Sensory needs Social, emotional and mental health Speech, language and communication needs Visual impairment Other Child 3 The year of birth of your third child who is disabled or has additional needs Please select 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 Primary diagnosis or condition Please select Attention Deficit Hyperactivity Disorder (ADHD) Autism Spectrum Conditions Cerebral palsy Downs syndrome Hearing impairment Heart condition Hemiplegia Learning disability Physical disability Rare condition Social, emotional and mental health Speech, language and communication needs Undiagnosed Visual impairment Other Prefer not to say Primary additional need, if relevant Please select Allergies Asthma Chronic or long term pain Complex health needs Diabetes Dyslexia Dyspraxia Epilepsy Hearing impairment Hypermobility Incontinence Learning disability Life-limiting or life-threatening condition Lung conditions Physical disability Profound and Multiple Learning Difficulty Sensory needs Social, emotional and mental health Speech, language and communication needs Visual impairment Additional diagnosis or need, if relevant Please select Attention Deficit Hyperactivity Disorder (ADHD) Allergies Asthma Autism Spectrum Conditions Cerebral palsy Chronic or long term pain Complex health needs Diabetes Downs syndrome Dyslexia Dyspraxia Epilepsy Hearing impairment Heart condition Hemiplegia Hypermobility Incontinence Learning disability Life-limiting or life-threatening condition Lung conditions Physical disability Profound and Multiple Learning Difficulty Rare condition Sensory needs Social, emotional and mental health Speech, language and communication needs Visual impairment Other SUBMIT