Do you consider yourself to have a disability? *

The Equality Act 2010 defines a disability as a physical or mental impairment that has a substantial and long-term adverse impact on an individual’s ability to carry out normal day-to-day activities.

Yes

No

Prefer not to say

Prefer not to say

Date

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DD

YYYY

Data Protection

By completing this form, and checking the box below, I agree to Raised In holding and processing the data I have provided, for its legitimate business reasons stated above.

I agree