Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Rt Hon
Sir
Lord
Sergeant
Dame
Lt Cdr
Sqn Ldr
Prince
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
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
Disabilities
No
Yes
A sensory disability
A physical disability
A learning disability
A mental health problem
Any other special need (please list in the 'Notes' section)
How would you like to be involved?
Stand for election to the Council of Governors
Receive general new and information about the hospitals
Be invited to meetings, lectures and other events
Be asked for my views on future plans
Be invited to join a project group to improve services
Volunteer at one of the hospitals
Help fundraise for the Trust in conjunction with the Trust's Charitable Funds
Service preferences?
Cancer
Cardiac
Childrens' Services
Cleanliness and Infection Control
Dementia / Old People
Dermatology
Diabetes
Disability
Ear, Nose and Throat
Hospital Food
Neurosciences and Neurology
Ophthalmology
Orthopaedics
Other (Please Specify)
Patient Services
Renal and Transplant
Specialist Services (Please Specify)
Women's Services
Do you work for either the Oxford University Hospitals NHS Foundation Trust, University of Oxford (in a department within the Medical Sciences Division), Carillion Services Limited, G4S or another PFI partner, based on a Trust site?
If so, please specify.
Carillion (Clinical)
OUH (Clinical)
MSD (Clinical)
G4S (Clinical)
OUH (Non-Clinical)
MSD (Non-Clinical)
Carillion (Non-Clinical)
G4S (Non-clinical)
3. Review
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
Disabilities
How would you like to be involved?
Service preferences?
If so, please specify.
4. Finish
*
I am applying to become a Member of Oxford University Hospitals NHS Foundation Trust (OUH). I agree to be bound by the rules of the Trust, and I understand that the Trust requires this information to meet its legal requirements as a public body and to exercise its official authority, as set out in UK law. I also understand that my personal information will only be used in relation to my membership of Oxford University Hospitals NHS Foundation Trust and not shared elsewhere.
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.