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 house name or number
	Postcode House name/number
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

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?	Taking part in surveys / consultations Attending health related events Standing for Governor Finding out about services and future plans Helping to develop services Volunteering
How did you hear about the Trust?	Wirral One Stop Shop WCT Employee Local Press Local group / word of mouth Trust Newsletter/poster in WCT service area School Careers Event

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?

*  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.

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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.