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
Cmdr
Deacon
Lord
Sir
Mx
First name *
Last 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 *
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
Disabilities
No
Yes
Prefer not to say
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?
Take part in discussion groups about services
I would also like to become a Member of Yeovil District Hospital NHS Foundation Trust
Do you have an interest in any particular aspect of our services?
Children & Young People
Community Services
Health Promotion
Learning Disabilities
Mental Health
Maternity
Research
Volunteering
Older People
Fundraising
How are you connected with the Trust?
A past patient
A past carer
A past member of staff
A current patient
A current carer
How did you hear about the trust?
Online Application
Public meetings
Public consultation mailing
Other (please list in 'Notes')
3. Review
Last Used Services
Title
First name
Last name
Date of birth
Gender
Address
County
Postcode
Home telephone
Mobile
Email
Ethnic Origin
Preferred method of contact
Disabilities
How would you like to be involved?
Do you have an interest in any particular aspect of our services?
How are you connected with the Trust?
How did you hear about the trust?
4. Finish
*
I apply to be a member of Somerset NHS Foundation Trust and be bound by the rules of the Trust’s constitution. 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.