Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Capt Wing Commander Col Major Commodore Cllr Sister Master Lady Mayor Alderman Brigadier Commander CDR RN Dame Group Captain Lt Cdr Lt Col Prebendary Rev Preb Rev Dr The Hon Sqd Ldr
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Date of birth *	DD MM YYYY
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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

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?	Consider standing for election as governor I'm happy to be contacted about meetings and surveys
Service preferences	Medicine Cancer Services Other support services (please list in ‘Notes’ section) Antenatal/Maternity Cardiology Infection Control Dermatology Ear, Nose & Throat Emergency Department Gynaecology Opthalmology Orthodontics Orthopaedic Paediatrics Surgery Trauma
How are you connected with the Trust?	I am a member of a community organisation I am a relative of a member of staff I am a relative of a patient I am a carer of a patient Other (Please Specify) I've been a patient at the RD&E Stakeholder
How did you hear about the trust?	Direct Mail Newspaper From another member At the Hospital RDEFT Website Governor Recruitment Session Recruit a Friend RDEFT Membership Stand

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
Disabilities
How would you like to be involved?
Service preferences
How are you connected with the Trust?
How did you hear about the trust?

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