Name of young person:

Date of birth: Day Month Year

Gender: Male Female 

Are you: A refugee An asylum seeker N/A 

Young person’s contact number:

Your email

Next of kin name:

Relationship:

Contact telephone of next of kin:

Do you identify yourself as disabled?
Yes No 

If ‘Yes’, please specify the nature of your disability

Support workers name:

Job Title:

Organisation name & address:

Support workers contact number:

Email:

Equal opportunities monitoring

We would be grateful if you would complete the following details about yourself. This information is entirely confidential and is only presented as statistics to Birmingham City Council and The Department for Communities and Local Government. By completing this section, you will help us monitor NYRG Membership.

Would you describe your ethnic origin as: (please tick the appropriate box)

Asian or Asian British – Bangladeshi Asian or Asian British - Indian Asian or Asian – Pakistani Asian or Asian British – Any Other Black or Black British – African Black or Black British - Caribbean 
Black or Black British – Any Other (please specify)

Chinese Mixed – White and Asian Mixed – White and Black African Mixed – White and Black Caribbean 
Mixed – White and Any Other (please specify)

White – British White – Irish White – Any Other 
Any other Ethnic Group

How would you define your sexuality

How would you define your religion

Do you live in
Supported Accommodation Own Tenancy 

How did you hear about NYRG?