We would very much like to ensure that all families using Sure Start Speke, and indeed all families living in the Speke area, are aware of the opportunities that Sure Start brings you and your children.

We would like your help because we need to know which services support you - the parents - in giving your children the best start in life.

Your completion of the following will give us (and those projects supported by Sure Start) your permission to:

• contact you about available services and those being developed
• include your family in the ongoing planning of Sure Start

We wish to reassure you that you have the right to view the information held by Sure Start.

Sender's Details

Your Name Your Email

Family Details

Family Name Family Address Post Code Telephone

Adults in Household

Name D.O.B. (dd/mm/yy) Disability *

* Please check this box if you have a disability or special needs

Children in Household

Name D.O.B. (dd/mm/yy) Ethnic Background Disability* Pull down to select   British   Irish   Other White   White/Black Caribbean   White/Black African   White Asian   Any other mixed background   Indian   Pakistani   Bangladeshi   Any other Asian background   Caribbean   African   Any other Black background   Other ethnic groups   Traditional Traveller   Any Other ethnic group Pull down to select   British   Irish   Other White   White/Black Caribbean   White/Black African   White Asian   Any other mixed background   Indian   Pakistani   Bangladeshi   Any other Asian background   Caribbean   African   Any other Black background   Other ethnic groups   Traditional Traveller   Any Other ethnic group Pull down to select   British   Irish   Other White   White/Black Caribbean   White/Black African   White Asian   Any other mixed background   Indian   Pakistani   Bangladeshi   Any other Asian background   Caribbean   African   Any other Black background   Other ethnic groups   Traditional Traveller   Any Other ethnic group Pull down to select   British   Irish   Other White   White/Black Caribbean   White/Black African   White Asian   Any other mixed background   Indian   Pakistani   Bangladeshi   Any other Asian background   Caribbean   African   Any other Black background   Other ethnic groups   Traditional Traveller   Any Other ethnic group Pull down to select   British   Irish   Other White   White/Black Caribbean   White/Black African   White Asian   Any other mixed background   Indian   Pakistani   Bangladeshi   Any other Asian background   Caribbean   African   Any other Black background   Other ethnic groups   Traditional Traveller   Any Other ethnic group

* Please check this box if your child has a disability or special needs