Please fill in your details below to become a member of Homerton University Hospital NHS Foundation Trust
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
Sir
Nurse
Freeman
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
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
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
Faith
No religion/Not stated
Christianity
Hinduism
Islam
Buddhism
Judaism
Sikhism
Other
2. Additional Information
Do you consider yourself to have a disability?
No
Yes
A sensory disability
A physical disability
A learning disability
A mental health problem
Any other special need (please specify)
How would you like to be involved?
Standing for election to the Council of Governors
Being consulted on by the Trust for new developments, changes to services, etc.
Attending meetings or events
Becoming a volunteer
Topics of interest?
Medicine
Women's health
Children's services
Surgery
National Spinal Injuries Centre
Outpatient services
Other support services (please specify)
How are you connected with the Trust?
A patient at Homerton
A carer of a Homerton patient
A volunteer at Homerton
How did you hear about the trust?
Online Application
Public meetings
Public consultation mailing
Other (please list)
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
Ethnicity
Faith
Preferred method of contact
Do you consider yourself to have a disability?
How would you like to be involved?
Topics of interest?
How are you connected with the Trust?
How did you hear about the trust?
4. Finish
*
I apply to be a member of Homerton University Hospital NHS Foundation Trust 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 Trust, 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.