Please confirm that your home address is in Bath & North East Somerset*

Please confirm that your home address is in Bath & North East Somerset*

Please tell us about your reason for contacting us, making sure you include as much detail as possible and stating what you would like us to do to help you *

Please tell us about your reason for contacting us, making sure you include as much detail as possible and stating what you would like us to do to help you *

Do you have any accessibility needs we should be aware of so that we can support you better? If not, please state ' No'

Do you have any accessibility needs we should be aware of so that we can support you better? If not, please state 'No'

Title

Forename(s)*

Surname*

Your house name/number and street name*

Town/City*

Postcode*

What contact method(s) would you like to provide *

Email Address*

Phone number (Please do not include spaces)*

Preferred contact method*

If we need to phone you, please tell us about any times when you will not be available 

Forename(s)*

Surname *

Date of birth *

Your house name/number and street name *

Town/City *

Postcode*

What contact method(s) would you like to provide *

Email address*

Phone number (Please do not include spaces)*

Preferred contact method*

If we need to phone you, please tell us about any times when you will not be available 

Current school or setting attended*

Ethnic group*

Gender*

Support level*

Forename(s)*

Surname*

What contact method(s) would you like to provide*

Email address*

Phone number (Please do not include spaces)
*

Preferred contact method*

If we need to phone you, please tell us about any times when you will not be available 

Please confirm you have read our Privacy Policy*

Please confirm you have read our Privacy Policy*

Please confirm you have read our Privacy Policy*

Where did you hear about us?

Where did you hear about us?

Where did you hear about us?

Are you happy to answer questions about yourself to ensure we are able to provide a fair and equitable service to all eligible people?*

What is your ethnic group*

What is your gender*

Do you consider yourself to be a Disabled person? (i.e. do you have physical or mental impairment which has a substantial long term adverse effect on your ability to carry out day to day activities?)*