This form must be completed by the person requesting the badge so that they fully understand what it means.

Full name:*

Job title:*

Email address:*

Full address of where you work so we can post a badge out to you:*

I confirm that:

I understand wearing a badge gives a positive message of inclusion and means I have a responsibility to be someone who is a friendly ear for LGBT+ young people and families

I have read the information on this page

I understand what to do if I think a situation requires escalation (refer people to information on our website www.yorkhospitals.nhs.uk/about-us/equality-and-diversity/lgbtq-at-this-trust)

By choosing to wear this badge, you are sending a message that “you can talk to me” about issues of gender and sexuality. You aren’t expected to solve all their issues and concerns but you are a friendly ear and will know how to signpost to support available.

We’d like to collect information about what motivates people to wear a badge which may be used anonymously to promote the badges to others.

Please tell us in a few words - I would like to wear a badge because:*