Arts 4 Dementia aims to create a culture that respects and values each other’s differences and to secure genuine equality of opportunity in all aspects of our work. We believe that our organisation should serve diverse communities and offer equal opportunities to the people it serves. 

Your responses to this form help us to know how well we’re progressing towards these goals.  Your answers are anonymous and confidential. Thank you!

Age

• 16-19
• 20-29
• 30-39
• 40-49
• 50-59
• 60-69
• 70-79
• 80-89
• 90+
• Prefer not to say

Gender

• Female
• Male
• Transwoman
• Transman
• Non-binary/ genderqueer/ agender/ gender fluid
• Prefer not to say
• Other

If 'other', please specify here if you wish:

Disability - do you consider yourself to have a disability?

• Yes
• No
• Prefer not to say

As defined by the Equalities Act 2010 as 'a physical or mental impairment which has a substantial and long term adverse effect on that person's ability to carry out normal day-to-day activities.'

Ethnic Origin

These categories were used in the 2021 Census. Which group(s) do you most identify with?

White

• English, Welsh, Scottish, Northern Irish and British
• Irish
• Gypsy Traveller
• Roma
• Any other white background (specify below)

If 'other', please specify here

Asian or Asian British

• Indian
• Pakastani
• Bangladeshi
• Chinese
• Any other Asian background (specify below)

If 'other', please specify here

Black, Black British, Caribbean or African

• Caribbean
• African
• Any other Black, Black British or Caribbean background (specify below)

If 'other', please specify here

Mixed or Multiple Ethnic Groups

• White and Black Caribbean
• White and Black African
• White and Asian
• Any other mixed background (specify below)

If 'other', please specify here

Other Ethnic Origin

• Arab
• Any other Ethnic Origin (specify below)

If 'other', please specify here

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