Member type	Public Patient
Title	Unspecified Mr Mrs Miss Ms Dr Reverend Professor Mx Cllr Sister Master Lady Mayor Lord Sir
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
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
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

How would you like to be involved?	Consider standing for election as governor Completed questionnaire How would you like to get involved - Ask me what I think about services How would you like to get involved - Invite me to member meetings How would you like to get involved - Send info about NTW Trust How would you like to get involved - Send me newsletters

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
Ethnic Origin
Preferred method of contact
Disabilities
How would you like to be involved?

*  I apply to be a member of Cumbria, Northumberland, Tyne and Wear 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.