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Mr
Mrs
Ms
Miss
Last Name
First name
Email Address
Street Address
Suburb
Postcode
Home Phone
Work Phone
Mobile
Do you live in Adelaide or the Mount Lofty Ranges?
If yes, which region do you live in (tick a box)
Northern – Barossa, northern Adelaide Plains
Central – central Adelaide Hills and central metropolitan Adelaide from foothills to the coast
Southern/Fleurieu – southern suburbs, McLaren Vale region and Fleurieu Peninsula, coastal communities from Christies Beach around to Port Elliot
None of the above
Not sure
If you do not live in the area, what is your connection? (tick a box)
I work there
I have family & friends there
I visit the area regularly for recreation/holidays
I do business there
Other
Gender
Male
Female
Age
16 years or under
17-25 years
26-40 years
41-60 years
60 plus
Are you involved with any community or industry groups which take an interest in natural resources management, environment or water issues?
If yes – what is the name of the organization?
Do you want to receive further communication about the project and water quality issues? This is mostly like to take the form of email notifications about events, new postings to the website, survey questionnaires, updates about the project its outcomes
How did you find out about the Community Panel?
Newspaper advertisement
Flyer received in the post
Flyer received by email
Healthy Waters website
From a friend
From a work colleague
Article in the local newspaper
Government website
Through a school
From my local library
From my local council
From a government agency
Poster
Open house event
Can't remember
Google or other search engine
Other
Would you be happy to receive SMS notifications on your mobile?
May we contact you by phone if your email is not working? We will only do this when email contact fails, as a means of still including you in the panel.