Fields marked with * are mandatory.
1. Personal Information
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
2. Additional Information
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
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
Ethnic Origin
Preferred method of contact
Disabilities
How would you like to be involved?
4. Finish
*
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.