Member type	Public Service user/Carer
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Capt Wing Commander Col Major Commodore Cllr Sister Master Lady Mayor Lord
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
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	Atheism Baha'i No Religion Buddhism Islam Christianity Hinduism Hinduism Rather Not Say Islam Jainism Judaism Jewish Pagan Not Stated Sikhism Other Does not wish to answer
Sexual Orientation	Bisexual Gay Heterosexual Lesbian Not Stated Do not wish to answer
Marriage/CP status	Civil Partnership Divorced Married Partnered Single Unspecified Widowed I do not wish to answer Prefer not to say Legally separated
Is your gender in which you live now different to that assigned at birth?	Unspecified Yes No Do not wish to answer

Disabilities	No Yes Dyslexia A sensory disability Learning disability A physical disability Mental health condition Any other special need (please list in 'Notes' section)
How would you like to be involved?	Level 1 - Informed: You will be made aware of new developments and information regarding Mersey Care, be able to participate in the elections of members to the Members Council and be invited to attend the Annual General Meeting. Level 2 - Involved: In addition to level 1, you will be invited to participate in a number of activities such as surveys, focus groups and special interest events. Level 3 - Active: In addition to levels 1 and 2 this level is aimed at members who express an interest in becoming a member of the Members Council or want to work actively with the organisation in another way (including helping in service development meetings and increasing your knowledge and skills in specific areas of interest). Volunteer at the Trust
Service preferences?	Adult mental health services Older People's mental health Asperger's service Brain injury services Community services Other (please list in 'Notes') Learning disability services Non-clinical services Participation opportunities Psychological services Recovery Learning Secure services Substance misuse services Young people's services Challenging stigma Forensic services Service user, carer and public involvement

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
Sexual Orientation
Marriage/CP status
Is your gender in which you live now different to that assigned at birth?
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?

*  I apply to be a member of Mersey Care NHS Foundation Trust and to 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.