Please fill in your details below to become a member of Wirral Community NHS Trust
Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Other
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
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
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
2. Additional Information
Special Contact Requirements
Large Print
Audio file by email
Audio file, or tape, by post
Braille
Other (we will contact you to discuss your needs)
Do you consider yourself to have a disability?
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)
Overall, how involved do you expect to be?
Information Only
Involved
Actively Involved
Are you interested in any of the following?
Attending health related events
Standing for Governor
Helping to develop services
Volunteering
Work experience placements
Apprenticeships
How did you hear about the Trust?
Local group / word of mouth
Local Press
School Careers Event
Trust Newsletter/poster in WCT service area
WCT Employee
Wirral One Stop Shop
Cheshire Show
Nantwich Show
Helpforce
Helpforce
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
Ethnicity
Special Contact Requirements
Preferred method of contact
Do you consider yourself to have a disability?
Overall, how involved do you expect to be?
Are you interested in any of the following?
How did you hear about the Trust?
4. Finish
*
I apply to be a member of Wirral Community NHS Trust and be bound by the rules of the organisation (available by emailing
foryouwithyou@wirralct.nhs.uk
). 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
here
for full details.
Please tick here if you consent to your details being added to the Public Register.