Please fill in your details below to become a member of Mersey Care NHS Foundation Trust. JOIN in
As a member for free and be involved as little or as much as you like
Find out about a wide range of health and wellbeing services
Share your views on how we can improve our services
Attend talks about subjects you're interested in and take part in surveys
Stand for election as a Governor or vote for a Governor.
Fields marked with * are mandatory.
1. Personal Information
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
2. Additional Information
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
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
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?
4. Finish
*
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
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for full details.
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