Please fill in your details below to become a member of York Teaching Hospital 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
Commodore
Cllr
Sister
Master
Lady
Mayor
Lieutenant colonel
The Revd Dr
Right Reverend
Father
Lord
Sir
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
2. Additional Information
Do you consider yourself to be disabled?
No
Yes
A sensory disability
A physical disability
A learning disability
A mental health problem
Any other special need (please enter below)
How would you like to be involved?
Find out more about the work of the Trust
Take part in consultation of the Trust's plans
Learn more about improving my own health, and be part of community health promotion campaigns
Volunteer at the Trust
Would like information on volunteering
Give feedback on services
Fundraising
Planning for the future
Consider standing for election as a governor
Ok to share information with third parties
Get involved in research at either the Trust, or our partner, the University of York.
What service areas are you interested in?
Gynaecology
Radiology and Pathology
Intensive care
Renal
Heart Disease
Eye problems
Accident and Emergency
Endoscopy
Haematology
Children's services
Asthma
Pain management
Cancer
Respiratory Illness
Rheumatology
Sexual health
Hearing problems
Dermatology
Ophthalmology
Orthopaedics
Anaesthetics
Maternity Care
Stroke
Diabetes
Urology
Gastroenterology
Care of the Elderly
Breast Cancer
Occupational Therapy
Palliative Care
Mental Health
Physiotherapy
Prevention
Rehabilitation Services
Public Health
How are you connected with the Trust?
A patient
A carer for someone who is a patient
Volunteer
Have worked for the Trust
No connection with the Trust
Interested member of the public
Current or former patient
How did you hear about Foundation Trust membership?
Online Application
Face to Face Recruitment
Through an employee of the Trust
Onsite leaflet
Media information
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
Preferred method of contact
Do you consider yourself to be disabled?
How would you like to be involved?
What service areas are you interested in?
How are you connected with the Trust?
How did you hear about Foundation Trust membership?
4. Finish
Membership is also open to all your friends and family so get them to complete an application form today for each person to benefit from NHS discounts, members only newsletter and events.
*
I apply to be a member of York Teaching Hospital 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
here
for full details.
Please tick here if you consent to your details being added to the Public Register.