Patient Participation Group Sign Up Title Mr Mrs Miss Ms Mx Dr Other First Names OptionalSurname OptionalEmail Enter Email Confirm Email Contact NumberPostcodeDate of Birth Day Month Year The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.Gender Male Female Other Your Age Under 16 17-24 25-34 35-44 45-54 55-64 65-74 75-84 Over 84 The ethnic background with which you most closely identify is:How would you describe how often you come to the practice? Regularly Occasionally Very Rarely Please select the type of involvement you wish to take:I wish to stay part of the Patient Participation group (PPG) as an inactive member receiving occasional emails about the practice or services Optional I wish to stay part of the Patient Participation group (PPG) as an active member taking part in actual meetings/gatherings (Please note that meetings take place during the day on weekdays) Optional