Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Service User
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Mx
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Const.
Sir
Nurse
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Prefer not to say
Please enter your postcode and click Get Address
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
We are keen to keep in touch with our members and would really appreciate it if you can let us know what your email address is to save on the cost of postage
Email *
Confirm email
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
Sensory Disability
Physical Disability
Mental Health Problem
Learning Disability
Other Disability
Visually Impaired
Hearing Impairment
How would you like to be involved? You can tick more than one box.
Receive Information
Attend (Educational) Events
Become part of a focus group
Take part in consultation of the Trust's plans
Consider standing for election as a Governor
Learn more about research
Volunteer at the Trust
Take part in fundraising
What areas are you most interested in? You can tick more than one box
Adult Mental Health
Older People
Children and Young People
Community Hospitals
How are you connected with the Trust?
Staff
Patient
Carer
Volunteer
Charity
Member of the Publlic
Ex NA Staff
How did you hear about the trust?
Website
Publication
Event
Friend or Relative
Other
Were you invited to join as part of our Gimme five campaign? If so please tell us who invited you.
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
Disabilities
How would you like to be involved? You can tick more than one box.
What areas are you most interested in? You can tick more than one box
How are you connected with the Trust?
How did you hear about the trust?
4. Finish
*
I apply to be a member of Oxford Health NHS Foundation Trust and be bound by the rules of the organisation. I give consent to the processing of my information.
Your details will held be on a database so that we can provide you with further information as a Member of the Trust. From time to time your details may be used by a third party for membership maintenance purposes, such as the administration of Governor Elections. The information you provide will remain confidential and will be managed 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.