Member type	Public Staff Patient & Carer
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Wing Commander Capt Col Major Commodore Cllr Sister Master Lady Mayor 1st Honourable ADV AB Brigadier Dame
First name *
Last name *
Middle name
Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Transgender
	Please enter your postcode, and house name or number
	Postcode House name/number
Address *
Town or City
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Postcode *
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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

It would be useful to know at this stage the level at which you would like to be involved. This does not represent a commitment on your part. (Please tick all that apply.)
How would you like to be involved?	Patient Services e.g. monitoring quality Patient Information e.g. proof reading leaflets Attending Meetings Volunteering Standing for Election as Governor Receiving Regular News from our Trust Research and Development
How did you hear about the Trust?	Face to Face Recruitment Referred by a friend Advertisement Through a Staff Member Online Membership Form Trust Website Ex-Staff Local Community Event Governor Other

Member type
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country	UK
Home telephone
Mobile
Email
Twitter
Ethnic Origin
Preferred method of contact
Disabilities
How would you like to be involved?
How did you hear about the Trust?

*  I apply to be a member of Mid Cheshire NHS Foundation Trust and be bound by the rules of the organisation. I give consent to the processing of my information.

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Please tick here if you do NOT want your name and constituency to be available to the public through the Foundation Trust Register of Members.