People’s Panel Application People's Panel Application Apply to be part of our People's Panel 1 Application form Warrington People2 Application Continued Section 1: Contact InformationName*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail How did you come across this advert*Healthwatch WebsiteVia a Patient, community or service user organisationSocial MediaPlease choose one.Section 2: Your personal experience and knowledgePlease Tell us about your understanding or experience of Health & Social Care and the issues to Warrington residents.*Can you demonstrate your ability to share people's views on Health & Social care in Warrington?*Please give examples of your communication and team-working skills that would be relevant for working with the other members of the panel?*Please give examples of your understanding of issues relating to equality relevant to this topic.*Please give us brief details of other skills, knowledge or experience or any other information relevant to your application that you have not already covered in this form.* Section 3: Futher InformationDo you have the time to commit to the work of the panel?* Yes No this includes attending meetings, reading papers, commenting on draft documents?Are you willing and able to keep the panels discussions confidential as appropriate* Yes No Have you worked, or do you work as a Healthcare, Social Care or Public Health Professional?* Yes No If yes, please give details including profession, speciality and dates:Is there anything that would stop you from sitting on the Panel?* Yes No For example conflict of interestIf yes, please give detailsSection 4: ReferencesPlease give us the name and contact details of 2 people who can tell us more about your suitability to be on the Peoples Panel. Your referees will be approached if you are invited to be a Panel member. The people you nominate as referees must not: be closely related by birth or marriage, or be in a relationship with or living at the same address as you -be a Healthwatch staff member. Referee 1Name:Relationship to you:*Address* Street Address Address Line 2 ZIP / Postal Code PhoneEmail Preferred Method of Contact* Email Phone Post Referee 2Name:Address* Street Address Address Line 2 ZIP / Postal Code Email PhonePreferred Method of Contact* Email Phone Post Consent I agree to the privacy policy.Would you like to sign up to Healthwatch Warrington's Mailing List?* Yes No Get up to date information on Health & Social Care information around Warrington and be kept up to date information on the work Healthwatch Warrington are doing.CAPTCHA Δ
