Member type	Public Patient
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Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Transgender
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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

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

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?

*  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.

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