Member type Please select your category from the options listed	Public Patient
Title	Unspecified Mr Mrs Miss Ms Mx Dr Professor Canon Wing Commander Reverend Capt Col Major Commodore Cllr Sister Master Lady Mayor Dame Lord The Reverend Dr The Right Honourable Sir
First name *
Last name *
Middle name
Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Non-binary Other
	Please enter your postcode and click Get Address
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
The trust is committed to saving money on printing, paper and postage and therefore only communicates regularly with members via email.
Email
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
Religion/Belief	Not Stated Atheism Buddhism Christianity Hinduism I do not wish to disclose my religion/belief Islam Jainism Judaism Other Sikhism Undefined
Sexual Orientation	Not Stated Heterosexual or Straight Gay or Lesbian Bisexual Other sexual orientation not listed Not Sure Prefer not to say

Special Postal Req	Large Print
Voting Preference	Electronic Voting (go green and also save the Trust vital funds) Paper Voting
Disabilities	No Yes A sensory disability A physical disability (mobility) A learning disability Mental Health Any other special need (please list in the 'Notes' section) Hearing Impaired Sight Impaired
How would you like to be involved?	Find out more about the work of the Trust General Trust news Information regarding research Interested in attending Medicine for Members Interested in attending public Council of Governors meetings Interested in attending the Annual Members Meeting Fundraising Take part in consultation of the Trust's plans Volunteer at the Trust Interested in being a Governor
Service preferences?	Medicine Women's health Children's services National Spinal Injuries Centre Surgery Outpatient services Other support services (please list in ‘Notes’ section) Cancer Services Stroke Services Heart and Lung Head and Neck Men's Health Medicine for the elderly Mental Health Emergency care Kidney and Liver
How are you connected with the Trust?	A patient past or present A carer of someone who is a patient Have worked for Trust in the past Live in the local area
How did you hear about the Trust?	Online Application Other (please list in 'Notes') Patient Mailing Face to face recruitment Through an employee of the Trust Patient information screens Leaflets Newsletter Media Trust website (www.cuh.org.uk)

Member type Please select your category from the options listed
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
Religion/Belief
Sexual Orientation
Voting Preference
Special Postal Req
Disabilities
How would you like to be involved?
Service preferences?
How are you connected with the Trust?
How did you hear about the Trust?

*  I apply to be a member of Cambridge University Hospitals NHS Foundation Trust and be bound by the rules of the Trust’s constitution. I give consent to the processing of my information.

The data you supply will be used only to contact you about the Trust, membership or other related issues and will be stored in accordance with the current Data Protection Act. Please click here for full details.

Foundation Trusts are required to publish a list of their public members. The only information published is your name and the constituency where you live. If you do want to appear on this list, please tick the box.