Please fill in your details below to become a member of Mid Cheshire NHS Foundation Trust.
Fields marked with * are mandatory.
1. Personal Information
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 click Get Address
Address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Twitter
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
2. Additional Information
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
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
Twitter
Ethnic Origin
Preferred method of contact
Disabilities
How would you like to be involved?
How did you hear about the Trust?
4. Finish
*
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.
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.