Please fill in your details below to become a member of Royal United Hospitals Bath NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Capt
Col
Major
Major General
Commodore
Cllr
Sir
Sister
Master
Lady
Mayor
Lord
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
Preferred method of contact
Email
Post
Telephone
SMS
Ethnicity
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
Faith
Not Stated
Atheism
Buddhism
Christianity
Hinduism
Islam
Jainism
Judaism
Sikhism
I do not wish to disclose
Agnostic
Other (please state in the notes box on selection)
Sexual Orientation
Not Stated
Heterosexual
Gay
Bisexual
I do not wish to disclose
2. Additional Information
Do you consider yourself to have a disability?
No
Yes
A physical disability
A sensory 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?
Keep in Touch - you'll receive a regular newsletter
Get Involved - attend events and help with surveys
Work with the NHS Foundation Trust - we'll keep you informed about becoming a Governor
Service preferences
All / Everything
Anything else? Add to the notes box below
Cancer services
Long Term Conditions
Older people's services
Outpatients
Urgent Care (Emergencies)
Women and Children's Services
How did you hear about the trust?
Caring for You event
Constituency Meeting
Elections
Employer (Please state)
Forever Friends Fundraising
Friends of the RUH
From a member of staff at RUH
Governor recruitment
GP or Surgery event
Hospital correspondence
Hospital Magazine - Insight
Letter through the door
Maternity
Membership Leaflet
Newspaper
Outpatient Appointment Letter
PALS/Complaints/Compliments
RUH Website
Staff Leaver
Thank You Letter
Welcome Letter
Word of mouth
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
Ethnicity
Faith
Sexual Orientation
Preferred method of contact
Do you consider yourself to have a disability?
How would you like to be involved?
Service preferences
How did you hear about the trust?
4. Finish
*
I apply to be a member of Royal United Hospitals Bath 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
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for full details.
Please tick here if you consent to your details being added to the Public Register.