Please fill in your details below to become a member of Bradford Teaching Hospitals NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Patient
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Reverend
Cllr
Father
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
What is your preferred method of contact?
Email
Post
Telephone
SMS
Monitoring information
We are committed to ensuring that all sections of our community are able to take part in our membership and patient/public activities. If you would provide us with the following information it will help us to determine what we need to do to make sure that all sections of our community have opportunities to take part.
What is your 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
What is your religion?
Not Stated
No religion
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other?
What is your sexual orientation?
Not Stated
Heterosexual
Lesbian/Gay
Bisexual
2. Additional Information
What languages do you speak? (please tick all that apply)
English
Urdu
Punjabi
Czech
Slovak
Polish
Bengali
Any other?
Do you consider yourself to be disabled?
No
Yes
Mobility
Learning difficulties
Hidden/other impairment
Wheelchair user
Blind/visually impaired
Living with HIV/Aids
Personal assistance user
Deaf/hearing impaired
Mental health needs
How involved do you want to be as a member?
Just receive routine membership communications
Register to take part in patient and public engagement activities aimed at improving patient experience
Register to take part in general surveys and consultations on long term strategic developments
Are you particularly interested in any of the following?
General membership events
Special events aimed at young people (16 to 25)
Forthcoming elections and the role of a Governor
Council of Governors quarterly meetings
The annual members meeting/annual general meeting
How did you hear about Foundation Trust Membership?
FT web site
Web search
Face to face recruitment
Another member
Trust event
Other NHS Site
Other
Membership Magazine
Have you ever received treatment provided by our Foundation Trust?
Yes, in the last 6 months
Yes, in the last 12 months
Yes, in the last 18 months
No
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
What is your ethnicity?
What is your religion?
What is your sexual orientation?
What languages do you speak? (please tick all that apply)
What is your preferred method of contact?
Do you consider yourself to be disabled?
How involved do you want to be as a member?
Are you particularly interested in any of the following?
How did you hear about Foundation Trust Membership?
Have you ever received treatment provided by our Foundation Trust?
4. Finish
*
I apply to be a member of Bradford Teaching Hospitals NHS Foundation Trust and be bound by the rules of the organisation. I give consent to the processing of my information.
Thank you for completing our online form - 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.