Please fill in your details below to become a member of Northern Care Alliance NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Staff
Title
Unspecified
Mr
Mrs
Miss
Ms
Mx
Dr
Professor
Canon
Wing Commander
Reverend
Rabbi
Capt
Col
Father
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Sir
Hon
Nurse
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Non-binary/third gender
Prefer not to say
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
SMS
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
Not Stated
Christianity
Judaism
Islam
Buddhism
Hinduism
Sikhism
Agnostic
Atheist
Other (please state)
No Religion
Sexual Orientation
Not Stated
Heterosexual
Homosexual
Bisexual
Transgender
2. Additional Information
Special Postal Requirements
Audio tapes
Braille
Large Print
Other (please list in ‘Notes’ section)
Disabilities
No
Yes
A learning difficulty
A mental health problem
A physical disability
A sensory disability
Any other disability or special need
What level of membership would you like?
Completed questionnaire
Informed (receiving newsletter,invitation to annual members' meeting,opportunity to comment on future plans)
Involved (as Informed plus invitation to attend events,talks on topics about health issues and hospital developments)
Active (as Involved plus invitation to take part in focus groups/special interest groups)
Interested in becoming a governor
Service preferences?
Accident and Emergency
Cancer Care
Children's Services (e.g. Health Visiting, School Nursing)
Clinical Support (e.g. x-rays, scans, pharmacy etc)
Community Services
Critical Care
Dental and Oral Health
Dermatology
Diabetes
District Nursing
Ear, Nose and Throat (including Audiology)
Elderly Care
Heart Care
Hospital Environment
Improving Future Communications
Intestinal Failure
Neurosciences
Orthopaedics
Other
Outpatients
Pain Services
Physiotherapy
Podiatry
Renal
Research and Clinical Trials
Respiratory
Rheumatology
Sexual Health
Stroke Services
Surgery
Urology
Volunteering
How are you connected with the Trust?
Salford Royal Staff
Pennine Acute Staff
Patient/Former Patient
Relative/Carer
Volunteer
Employee
Former Employee
General Public/No Specific Connection
Work Experience
Veteran
How did you hear about the Trust?
Advertising
Face-to-Face Recruitment
NCA Website
Patient Mailing
Through an employee of the Trust
Twitter Link
Work Experience
Student Recruitment
Volunteering
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
Ethnicity
Faith
Sexual Orientation
Special Postal Requirements
Preferred method of contact
Disabilities
What level of membership would you like?
Service preferences?
How are you connected with the Trust?
How did you hear about the Trust?
4. Finish
*
I apply to be a member of Northern Care Alliance 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
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for full details.
Please tick here if you consent to your details being added to the Public Register.