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Disabilities	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)
How would you like to be involved?	Would consider standing as a governor Newsletter only Newsletter and events Newsletter, events, additional mailings/consultations Wants to participate in public consultation I Would Like to Register as a Member of East Midlands Ambulance Service (EMAS)
Your interests	Medical Matters Patient information Hospital environment Auditing our services Future service development Patient food and menus Faith needs Minority community needs Employment opportunities Carers’ needs and support The Nottingham University Hospital Charity Our role as an organisation supporting local communities
Are you a member of any connected organisations?	Member of East Midlands Ambulance Service Member of Sherwood Forest Hospitals NHS Foundation Trust Member of Nottinghamshire Healthcare NHS Trust

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