You can become a member of Derbyshire Healthcare NHS Foundation Trust by completing the below application form.
Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Capt
Major
Wing Commander
Col
Commodore
Cllr
Sister
Master
Lady
Mayor
Brigadier
Inspector
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Transgender
I prefer not to say
I prefer to use my own term
Please enter your postcode and click Get Address
Home 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
Faith
Not Stated
Agnostic
Atheist
Buddhism
Christian
Hindu
Jewish
Muslim
No Religion
Pagan
Sikh
Other
Prefer Not To Say
Sexual Orientation
Bi man
Bi woman
Gay man
Gay woman/lesbian
Straight
Prefer Not To Say
I prefer to use my own term
2. Additional Information
Do you consider yourself to be disabled?
No
Yes
Prefer not to say
A sensory disability
A physical disability
A learning disability
A mental health problem
Any other special need (please state)
Service interests
Children's services
Drug and Alcohol Services
Eating Disorder Services
Elderly Care including Dementia
Learning Disabilities Services
Mental Health Services
Relationship with the Trust
Carer
Former Service User
Service User
Student
Volunteer
Other (please state)
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
Faith
Sexual Orientation
Preferred method of contact
Do you consider yourself to be disabled?
Service interests
Relationship with the Trust
4. Finish
*
I apply to be a member of Derbyshire Healthcare 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.