Application to Attend focus group with Maternity Action
* Please complete this application with as much information as possible.
* This focus group is for European Expats only (anyone with current or past European nationality).
* You are welcome to bring your child/children to the focus group.
* Focus group facilitator: Annah Psarros, Senior Policy Officer (Health and Wellbeing) at Maternity Action.
* We have only 10 spaces available (first come first serve).
Are you available to attend the focus group on the 27th of January 2018 at Europia office (M15 5BJ) from 12:00 until 14:30?
Full name
Your answer
Telephone number
Your answer
Email address
Your answer
Full address including postcode
Your answer
Nationality
Your answer
Marital status
Do you have any children?
If you have children, how many? And how old are they?
Your answer
Are you currently pregnant ?
Are you currently trying to conceive or planning to conceive in the next two years?
Are you employed?
If you are employed, what is your employment status?
Do you live alone, with a spouse/partner or with other people?
Your answer
Do you have any help in raising your child(ren)? Either financial or practical?
Your answer
Do you receive any child support benefit or will you be applying for benefits once you have a child?
Your answer
Do you have any ongoing medical issues/ conditions?
Your answer
Do you smoke?
Do you drink?
Do you follow a particular diet (vegetarian, vegan, etc.)?
Have you used or do you currently use any services aimed for pregnant women/mothers/women who try to get pregnant? Please dive details.
Your answer
What is your estimated yearly family income?
Can you speak communicative English? If your answer is no, tell us which language do you prefer to communicate in?
Your answer
Thank you!
We will contact you within 3 working days to let you knwo if you have been granted a place in this focus group.
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