First name
Last name
Email
Home phone number
1.
Select your age bracket
Please select
14-18
18-24
25-34
35-44
45-54
55-64
65+
2.
What suburb do you live in?
Please select
Churchlands
City Beach
Doubleview
Floreat
Glendalough
Osborne Park
Scarborough
Wembley
Wembley Downs
West Leederville
Woodlands
Other
3.
How do you describe your gender?
Please select
Woman
Man
Non-binary
Prefer not to say
Other
4.
What do you value about living here? What do you think makes our community unique?
5.
What do you think is the biggest problem with politics?
6.
What do you think are the qualities of a really good political representative?
7.
From the list below select the top 5 issues that are most important to you.
Cost of living
Public health
Public transport
Integrity in politics
Housing affordability (including renters)
Reconciliation for First Nations people
Planning and development
Education
Socioeconomic inequality
Environment and sustainability
Disability support
Access to childcare
Support for local businesses
Social inclusion
8.
What do you think the biggest issues facing our community will be in the next 5 years?
9.
Is there a local issue that you think is not getting enough political attention?
10.
Would you consider supporting an independent candidate?
Please select
Yes
No
11.
How did you come across this survey?
12.
Would you like to volunteer with Churchlands Independent?
Please select
Yes
No