Please fill in your details below to become a member of Ashford and St. Peter's Hospitals NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Dr
Ms
Professor
Reverend
Canon
Wing Commander
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Lieutenant colonel
Second lieutenant
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
Post
Telephone
SMS
Ethnicity
Not stated
White - English, Welsh, Scottish, Northern Irish, British
White - Irish
White - Gypsy or Irish Traveller
Mixed - White and Black Caribbean
White - Other
Mixed - White and Black African
Mixed - Other Mixed
Mixed - White and Asian
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
2. Additional Information
Do you consider yourself to be disabled?
No
Yes
A sensory disability
A physical disability
A learning disability
Any other special need (please list in the 'Notes' section)
A mental health problem
How would you like to be involved?
Attend meetings/events
Receive regular information
Volunteer at the Trust
Consider Standing for Election as a Governor
Service preferences?
Cancer
Diabetes
Maternity
Services for Young People
Stroke
Other (please list in ‘Notes’ section)
How did you hear about the Trust?
Patient mailing
Face to face recruitment
Mail Shot
Radio Advertisement
Through an employee of the Trust
Other (please list in 'Notes')
Internet
Paper
Newsletter
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
Preferred method of contact
Do you consider yourself to be disabled?
How would you like to be involved?
Service preferences?
How did you hear about the Trust?
4. Finish
*
I apply to be a member of Ashford and St. Peter's Hospitals NHS Foundation Trust and be bound by the rules of the organisation. I give consent to the processing of my information.
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for full details.
We are obliged to keep a register of our members. If you consent to your details to be placed on the public edition of the register, please tick this box.