Queen Victoria Hospitals NHS Foundation Trust

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Last name *
Date of birth *	DD MM YYYY
Gender
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Home tel *
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Email
We like to keep in touch with our members by email as it is a fast and cost-effective way of keeping you up-to-date. If you would be happy to receive our news by email, please enter your email address above. We will only use it for membership matters and will not pass it on for the use of any third party. Thank you.
QVH has a legal duty not to discriminate. This duty applies to the way we treat our members as well as our patients and staff. We take this duty seriously and believe that equality legislation gives us opportunities to improve the quality of QVH care, employment and membership. Your answers to the following questions help us to make sure that we treat everyone equally, fairly and as well as we possibly can. Some questions may seem unusual because they are about aspects of your life that are private. The information you give us will be held securely and used anonymously, only in ways which will help QVH to meet its equality, diversity and human rights duties and to deliver high-quality care. But you do not have to answer the questions and you can still become a member if you choose not to. Thank you.
Ethnicity



Are you now or have you ever considered yourself as transgender?

Disability: Do you consider yourself to be disabled?

Please tick one or more of the following options if you would consider getting more involved with the trust:

Standing for election as a governor

Volunteering at the hospital

Helping with events/activities in my local area

Fundraising

We would like to know which of the following you are interested in so we can keep you updated on the things that matter to you:

Plastic Surgery and Burns

Corneoplastics and Ophthalmology (eyes)

Head, Neck and Dental

Therapies

Paediatrics (Peanut Ward)

Minor Injuries Unit

Outpatients

QVH Charitable Fund

Are you already connected to the trust in any of the following ways?

I am/have been a QVH patient

I am/have been a QVH volunteer

I am a relative or carer of a QVH patient

I have previously worked for the trust

How did you hear about foundation trust membership?

QVH site, newsletter or leaflet

Media (TV, radio, newspapers)

From a friend or relative

QVH Website

From a QVH governor or member

From a QVH employee or volunteer

Title

First name

Last name

Date of birth

Gender

Address

County

Postcode

Country

UK

Home tel *

Mobile

Email

Ethnicity

Are you now or have you ever considered yourself as transgender?

Disability: Do you consider yourself to be disabled?

Please tick one or more of the following options if you would consider getting more involved with the trust:

We would like to know which of the following you are interested in so we can keep you updated on the things that matter to you:

Are you already connected to the trust in any of the following ways?

How did you hear about foundation trust membership?

* I apply to be a member of Queen Victoria Hospitals NHS Foundation Trust and be bound by the rules of the organisation. By ticking this box I agree that I am over 18 years and live in Kent, Surrey or Sussex or the London borough of Croydon, Kingston, Merton, Richmond, Sutton, Bexley, Bromley, Greenwich, Lambeth, Lewisham, Southwark or Wandsworth (or live outside the area and wish to become an affiliate member).

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 Data Protection Act. Please click here for full details.

Please tick here if you do NOT want your name and constituency to be available to the public through the Foundation Trust Register of Members.