Sign Our e-Petition

The remainder of this page concerns registration for our on-line petition. This will be the hub of our argument against water fluoridation in Bedfordshire. We intend to collect enough signatures to make the Beds and Herts Strategic Health Authority reopen the consultation process on water fluoridation in the county. At this stage, it doesn't matter if you're against fluoridation or undecided. When we get a proper consultation process established, everyone will get to hear both sides of the story and make their own minds up.

To provide verifiable proof that our petition represents local strength of feeling, we do need to collect address details and you must live in Bedfordshire. However:

We promise that your information will remain entirely confidential. It will not be used for any marketing purposes or spamming. The only organisation to receive your details will be the Health Authority when we submit the petition unless you tell us otherwise.

First, what is your opinion of water fluoridation?  <Please Select One> For It Against It Neutral Still Information Gathering

(Please note that the orange fields must be completed in the following sections.)

On-line Details

Please provide an e-mail address if you want to receive e-mail updates. If you want make submissions to the discussion forum, then please also provide a user name. This means that your submissions will be anonymous unless you choose to publicise your e-mail address. If you want to update these details at a later date, you MUST enter either an e-mail address or a user name, plus the password. Click here for more information on e-mail addresses and user names.

E-mail Address:
	Check this box if you want to receive e-mail updates on the campaign, such as upcoming meetings or events, or changes to the site for example.
	Check this box if you want to receive e-mail updates on other health issues which we may feature from time to time.
User Name:
Password:
Confirm Password:	(Same password is entered twice for confirmation.)

Organisation / Company Details

Organisations and companies will be listed separately in the petition. If you are qualified to fill in the petition on behalf of your entire organisation, then please fill in the organisation details below as well as the Personal Details section. If not, just skip straight to the Personal Details section.

 Check this box if you want to add an organisation or company to the petition and you are qualified to do this on their behalf

Organisation Name:
Number/Street:
Street 2:
Town/City:
County:
Postcode:
Comment (included on petition entry):

Personal Details

First Name:
Last Name:
Number/Street:
Street 2:
Town/City:
County:
Postcode:
Telephone:	-> Convenient for us if you want to help out
Comment (included on petition entry):
Feedback to us (any improvements you'd like etc):

	Check this box if you or anyone you know has been affected by dental fluorosis, or other fluoride related problems, and we can contact you about it.
	Check this box if we can list your name and town (NOT YOUR ADDRESS!!) in the on-line petition, e.g. 'John Smith, Bedford'. Otherwise, if you lived in Bedford for instance, you would be listed as 'Anonymous, Bedford'.
	Check this box if you are willing to help in any way. E.g. at meetings, events, distribution of information or collecting signatures locally.
	Check this box if you would like your petition entry to be included in the national campaign against water fluoridation run by the National Pure Water Association. This means your details would be forwarded to them.
	Check this box if the issue of water fluoridation could affect your vote at election time.
	Check this box if you would like the site to remember you when you return. This way, you can quickly change your details here, or contribute to the discussion forum without being required to enter your e-mail address and password again. Do NOT use this option on public computers, like those at internet cafe's or other users may be able to change/access your details.