Bereaved Families Panel Please fill in this form to register for the Bereaved Families Panel Bereaved Families Panel – Registration Form Name* First Last Email* Phone*Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What is your gender?*-Select-MaleFemaleI prefer to self-describeIf you prefer to self-describe please provide this hereAge range*SelectUnder 1818-24 years old25-34 years old35-44 years old45-54 years oldOver 55Please choose one option that best describes your ethnic group or backgroundWhite English / Welsh / Scottish / Northern Irish / British Irish Gypsy or Irish Traveller Any other White background Mixed / Multiple ethnic groups White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Asian / Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background Black / African / Caribbean / Black British African Caribbean Any other Black / African / Caribbean background Other ethnic group Arab Any other ethnic group Please specify ethnic groupHow many years bereaved are you?*What is your relationship with the child who died?*- Select-MotherFatherGrandfatherGrandmotherSiblingAuntUncleOther- please specifyIf other - please specify hereHow old was your baby/child when they died?*Which of these most closely describes your baby or young child's cause of death?*-Select-SIDS - Sudden infant death syndromeSUDC - sudden unexplained death in childhoodA stillbirthA neonatal deathAn illness or genetic conditionAn accidentCause is not yet known (awaiting post mortem results)Other (please tell us)Other (please tell us)Have you used the LT bereavement service, including CONI support, before?*-Select-YesNoIf Yes, please specify which serviceSelectHelplineOnlineBereavement Support GroupBefriending serviceCONI ProgrammeVolunteering as a Bereaved Families Panel memberPlease note this is not a support group and we ask you are at least 2 years bereaved and feel comfortable talking about bereavement without it becoming a trigger for you. The commitment of the Bereaved Families Panel is to take part in 3 meetings a year (online) with ad hoc requests for help with resources, campaigns, consultation via email as and when.What would you like to get from the Bereaved Families members panel?*SelectFriendship / part of a communityHelping to shapes services for future familiesOtherIf Other, please let us know what you would like to get from this experience:Please tell us – is a few words (no more than 25 words) why you would like to be part of this group?*We are always looking for families to be part of our film campaigns. Would you like to be involved?*SelectYesNoMaybeBereaved Families Panel Code of ConductEvery member of the Bereaved Families Panel must:1. Treat each other as an individual. 2. Support each member’s own individual choice about their own involvement within the Bereaved Families Panel. 3. Respect each person’s personal views and wishes. 4. Respect and maintain the dignity and privacy of members of the Bereaved Families Panel. 5. Respect diversity and different cultures and values and experiences of all members of the Bereaved Families Panel. 6. Be honest and trustworthy. 7. Communicate in an appropriate, open, accurate and straightforward way whilst making sure their actions, opinions and/or behaviour does not affect themselves or others in a negative way. 8. Be reliable, dependable and honour commitments, agreements and arrangements and, when it is not possible to do so, let the support team know. 9. Declare issues that might create conflicts of interest. 10. Strive to support the Lullaby Trust to the best of your ability and for the time indicated when you initially signed up, unless otherwise indicated to the Support Team. Our promise to you as the professionals involved in the Bereaved Families Panel :1. We will respect and, where appropriate, promote your individual views and wishes, working openly and co-operatively with all members. 2. We will promote equal opportunities for all members. 3. We will maintain confidentiality of all personal information. All information about you will be held in accordance with our Privacy Policy. See our privacy policy on our website for how we collect, use and look after personal information at https://www.lullabytrust.org.uk/privacy-cookies 4. We will respect all responses and remain impartial and non-judgemental whilst clearly explaining policies about confidentiality, the breaking of confidentiality, and the reporting of dangerous, abusive, discriminatory or exploitative behaviour. We will not tolerate abusive or inappropriate behaviour or language being used within the group; you may be asked to leave the group.5. We will uphold public trust and confidence in the Bereaved Families Panel by acting in a lawful, safe and effective way. 6. We will be accountable for maintaining and improving the quality of the Bereaved Families Panel work. 7. We will protect the rights and promote the interests of all members, taking compliments and complaints seriously and responding to them by passing them to the appropriate person. 8. We will strive to establish and maintain the trust and confidence of all members. By agreeing, you are confirming that you:• Will abide by ‘Bereaved Families Panel Code of Practice' • Understand the role and responsibilities of the Support Team staff involved with the Bereaved Families Panel Do you agree with the Bereaved Families Panel Code of Practice?*SelectYes, I agreeNo, I don't agree