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Cancer SMART Apply
Which role are you applying for?
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Digital Champion
Cancer Champion
First Name
Last Name
Email
Phone Number
Postcode
Region
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Harrogate
Bradford
Calderdale
Kirklees
Leeds
Wakefield
Other
Facebook Account Name
We need this so we can invite you to our Facebook Digital Champions group.
Could you tell us why you would like to get involved in Cancer SMART?
Gender
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Female
Male
Trans
Non-binary
Intersex
Other
Prefer not to say
Not known/not asked
Age Band
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18-24
25-44
45-64
65-74
75-84
85+
Religious Belief
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Buddhist
Jewish
Christian
Muslim
Hindu
Sikh
Other Religion
None
Prefer not to say
Unknown
Ethnic Group
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White: British / English / Scottish / Welsh / Northern Irish
White: Irish
White: Gypsy, Traveller or Irish Traveller
White: Roma
White: Any other White background (please describe)
Mixed / Mulitple ethnic groups: Black Caribbean and White
Mixed / Mulitple ethnic groups: Black African and White
Mixed / Mulitple ethnic groups: Asian and White
Mixed / Mulitple ethnic groups: Any other Mixed/Multiple ethnic groups background (please describe)
Asian / Asian British: Indian
Asian / Asian British: Pakistani
Asian / Asian British: Bangladeshi
Asian / Asian British: Chinese
Asian / Asian British: Any other Asian background (please describe)
Black / Black British: African
Black / Black British: Caribbean
Black / Black British: Any other Black / Black British background (please describe)
Other: Arab
Any other ethnic group
Prefer not to say
Not known
Other Ethnicity (please describe)
Do you have a disability?
Yes
No
Note - The Equality Act 2010 considers a person to be disabled if they have a “mental or physical impairment that has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities”. You do not need to be registered disabled.
Disability
Dexterity
Mobility
Hearing
Learning or understanding or concentrating
Memory
Mental Health
Social or behavioural
Stamina or breathing or fatigue
Vision impairment
Other
Not known
Prefer not to say
Wheelchair user
Long term condition, e.g. cancer, HIV, diabetes, chronic heart disease or epilepsy
Details of Disability
Digital Champion Guidelines
Link to the "Guidelines for Digital Champions" document
I have reviewed and agree with the Digital Champion Guidelines
Would you like to receive the newsletter?
Yes
No
Privacy Policy
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