Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Staff
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Father
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
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Preferred method of contact
Email
Post
Telephone
SMS
Ethnic Origin
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
Sexual Orientation
Not Stated
Bi-sexual
Heterosexual
Lesbian
Gay
Do not wish to disclose
2. Additional Information
Voting Preference
Postal Voting Preference
Electronic Voting Preference
Disabilities
No
Yes
A sensory disability
A physical disability
A learning disability
Any other special need (please list in the 'Notes' section)
ADHD
Arthritis
A respiratory disability
A hearing problem
Diabetes
Long Standing Illness
Mental Health
How would you like to be involved?
Consider standing for election as governor
Interested in Volunteering
Interested in hearing about all hospital events
Current volunteer at BDGH
3. Review
Member type
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Ethnic Origin
Sexual Orientation
Voting Preference
Preferred method of contact
Disabilities
How would you like to be involved?
4. Finish
*
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