Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Staff
Patient
Organisation
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Capt
Wing Commander
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
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
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
Religion/Belief
Not Stated
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
No religion
Other
Do not wish to disclose
Sexual Orientation
Not Stated
Heterosexual
Gay/Lesbian
Bi-sexual
Do not know / not sure
Do not wish to disclose
2. Additional Information
Which CCGs are you interested in?
Cumbria CCG
Gateshead CCG
Newcastle North and East CCG
Newcastle West CCG
North Tyneside CCG
Northumberland CCG
South Tyneside CCG
Sunderland CCG
Disabilities
No
Yes
A sensory disability
Hearing
Behaviour or emotional
A mental health problem
A physical disability
Long standing illness
A learning disability
Any other special need
How would you like to be involved?
Complete surveys
Attend events
Receive information
Attend focus groups
Service preferences?
Cancer care
Children and young person's health and care
Community services
End of life care
GP surgeries and primary care
Health improvement and reducing health inequalities
Hospital care
Long term conditions
Maternity and new born care
Mental health and wellbeing
Older people's health and care
Pharmacies and medicines
Planned care eg services and treatments which are not carried out in an emergency
Staying healthy
Support for carers
Urgent Care eg services and treatments which are carried out in an emergency
How are you connected to the CCG?
Work for the CCG
Member of CCG (work in GP practice)
Work in the NHS eg hospital trust, ambulance trust, mental health trust, community services
Have previously worked for a NHS organisation
Work in partnership with CCG ie local council, community voluntary sector
No connection
How did you hear about the CCG?
Face-to-face recruitment
Radio advertisement
Website
Mail out
Event
Other
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
Religion/Belief
Sexual Orientation
Which CCGs are you interested in?
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?
How are you connected to the CCG?
How did you hear about the CCG?
4. Finish
*
I apply to be a member of My NHS and be bound by the rules of the organisation. I give consent to the processing of my information.
The data you supply will be used only to contact you about the CCG, membership or other related issues and will be stored in accordance with the current Data Protection Act. Please click
here
for full details.
Please tick here if you consent to your details being added to the Public Register.