Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Canon
Capt
Cllr
Col
Commodore
Dame
Dr
Lady
Lord
Lt Col
Major
Master
Mayor
Miss
Mr
Mrs
Ms
Professor
Rabbi
Rev Dr
Reverend
Sir
Sister
Wing Commander
Arcduke
First name *
Last name *
Date of birth
DD
MM
YYYY
How do you personally describe your gender?
Unspecified
Woman
Man
Transgender Woman (MtF)
Transgender Man (FtM)
Non-binary/gender fluid
Agender/I don’t identify with any gender
Prefer not to say
Don’t know
Other'
Please enter your postcode and click Get Address
Postcode
House name/number
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Preferred method of contact
Email
Post
Telephone
SMS
Please describe your 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
Please indicate your religion or belief:
Not Stated
Christian
Muslim
Hindu
Jewish
Please select the option which best describes your sexuality:
Not Stated
Heterosexual
Homosexual
Bisexual
Transgender
2. Additional Information
What is your first language?
English
Urdu
Arabic
Chinese
Spanish
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
How would you like to be involved?
Consider standing for election as a governor
Find out more about the work of the trust
Take part in consultation of the Trust’s plans
Advocate for the trust within the community
Volunteer at the Trust
Learn more about how to improve health and take part in health promotion campaigns in community
Service preferences?
Outpatients
Other
Maternity
Care of the elderly
Women’s and Children’s services
Cancer
A&E
Diagnostics
Specialist Services
How did you hear about the trust?
Online Application
Patient Mailing
Face to Face recruitment
Advertisement / media item
Through an employee of the Trust
Through a Governor of the Trust
At an event
KGH website
3. Review
Last Used Services
Title
First name
Last name
Date of birth
How do you personally describe your gender?
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Please describe your ethnic origin:
Please indicate your religion or belief:
Please select the option which best describes your sexuality:
What is your first language?
Preferred method of contact
Do you consider yourself to have a disability?
How would you like to be involved?
Service preferences?
How did you hear about the trust?
4. Finish
*
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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
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for full details.
Please tick here if you consent to your name and Constituency being added to a Public Register of Members which we are legally required to make available upon request (see our Privacy Notice for more information.)