Please give us a few details about yourself to become a member of Rodney District Council's new Citizens' Panel. The information you give us will help us to make sure that the panel includes a wide range of perspectives from the people and communities who live within the Rodney District. You will receive up to six surveys during the coming year and will be able to opt out at any time should you decide you are too busy or you are not interested in staying involved.

First name Last name Email address Which town or community do you live in? Algies Bay Coatesville Dairy Flat Helensville Huapai Kaipara Flats Kaukapakapa Kawau Kumeu Leigh Mahurangi Matakana Muriwai Beach Omaha Orewa Pakiri Point Wells Port Albert Puhoi Riverhead Shelly Beach Silverdale Snells Beach Stillwater Tapora Tauhoa Taupaki Waimauku Wainui Waitoki Waiwera Warkworth Wellsford Whangaparaoa Woodhill Other (please specify) Age group 16-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75 and over Gender Male Female Ethnicity NZ European Maori Pacific Peoples Indian Chinese Other (please specify) How long have you lived in the Rodney District? 0-5 years 5-10 years 10+ years Which of the following best describes your current work status Full time employed Part time employed Parent/guardian Retired Unemployed Student Other (please specify) Which of the following best describes the household you live in? One person living alone Couple with no children Two parent family One parent family Non family household - eg flatting Extended family arrangement Other (please specify) Do you currently work for Rodney District Council? Yes No Please let us know of any community organisations within Rodney you are actively involved with