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
Pastor
Nurse
Father
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Transgender
Please enter your postcode, and house name or number, and click Get Address
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Twitter
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
Gay
Heterosexual
Lesbian
Not Stated
Prefer not to say
Marriage/CP status
Unspecified
Divorced
In a civil partnership
Married
Not Stated
Single
Widow/Widower
2. Additional Information
Special Postal Req
Large Print
Audio tapes
Braille
Other (please list in ‘Notes’ section)
Voting Preference - Electronic
Voting Preference - Postal
Disabilities
No
Yes
A sensory disability
A physical disability
A learning disability
A mental health problem
Any other special need (please list in the 'Notes' section)
How would you like to be involved?
Consider standing for election as governor
Completed questionnaire
Attend meetings
Attend events
Consider standing for election
Receive regular information
Service preferences?
Medicine
Women's health
Children's services
Surgery
National Spinal Injuries Centre
Outpatient services
Other support services (please list in ‘Notes’ section)
How are you connected with the Trust?
A past patient
How did you hear about the trust?
Online Application
Public meetings
Public consultation mailing
Other (please list in 'Notes')
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
Twitter
Ethnic Origin
Sexual Orientation
Marriage/CP status
Special Postal Req
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?
How are you connected with the Trust?
How did you hear about the trust?
4. Finish
*
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