Please fill in your details below to become a member of Airedale NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Deacon
Lieutenant-Colonel
The Reverend Canon
Lord
Sir
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Transgender
Please enter your postcode, and click Get Address
Address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Preferred method of contact
Email address (we tend to communicate with our members via email and generally only use post to tell people about our elections)
Ethnicity
Not stated
White - English, Welsh, Scottish, Northern Irish, British
White - Irish
White - Gypsy or Irish Traveller
White - Other
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Other Mixed
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Other Asian
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Other Black
Other Ethnic Group - Arab
Other Ethnic Group - Any Other Ethnic Group
Faith
Not Stated
Atheism
Buddhism
Christianity
Hinduism
Islam
Jehovah's Witnesses
Judaism
Rastafari
Sikhism
Spiritualism
Other
Sexual Orientation
Not Stated
Heterosexual
Lesbian
Gay
Bisexual
Transexual
2. Additional Information
Special Postal Requirements
Language other than English
Disabilities
No
Yes
Prefer not to say
Please Enter
How would you like to be involved?
Level 1 - I am happy just to receive email updates and invites to events
Level 2 - Get involved – I might like to give you my views by taking part in surveys and focus groups
Level 3 - Work with us - I might be interested in standing for election as a Governor in the future and would like to receive more information and/or come to a governor information event.
How are you connected with the Trust? (Please select all the options that apply)
Patient
Carer
Parent of patient
Member of public
Non-staff Volunteer
Have previously worked for Trust
Other
3. Review
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Ethnicity
Faith
Sexual Orientation
Special Postal Requirements
Preferred method of contact
Disabilities
How would you like to be involved?
How are you connected with the Trust? (Please select all the options that apply)
4. Finish
*
Declaration: I apply to become a Member of Airedale NHS Foundation Trust. I agree to be bound by the rules of the organisation and I understand that the processing of my information is for the purposes of the Trust to meet the legal requirements set out in UK law, or exercise the official authority established for a Foundation Trust as a public body.
I also understand that my personal information will only be used in relation to my membership of Airedale NHS Foundation Trust and not shared elsewhere, and will be stored in accordance with the Data Protection Act. 2018 and the General Data Protection Regulation (GDPR) 2016. Please click
here
for full details.
Your membership details will be held and used in accordance with all relevant legal requirements. By law, we are required to make registers available to the public. However, the public registers must exclude any public members who do not wish to be included. The public register shows the member’s name and constituency but not their address or any other personal details. By default we exclude your details, so please click here if you wish to appear.