Fields marked with * are mandatory.
1. Personal Information
Member type
Individual
Organisation
Organisation
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
JP
OBE
The Right Honourable
Sir
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Transgender
Please enter your postcode, and house name or number, and click Get Address
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Preferred method of contact
Email
Post
Telephone
SMS
Ethnic Origin
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
Religion/Belief
Not Stated
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
No religion
Other
Do not wish to disclose
Sexual Orientation
Not Stated
Heterosexual
Gay/Lesbian
Bi-sexual
Do not know / not sure
Do not wish to disclose
2. Additional Information
Languages
Please state:
Disabilities
No
Yes
A sensory disability
Hearing
Behaviour or emotional
A mental health problem
A physical disability
Long standing illness
A learning disability
Any other special need
How would you like to be involved?
Attend events / meetings
Attend focus groups
Being involved in planing/developing and monitoring of services
Complete surveys/questionnaires
Help to develop better information for service users
Service preferences?
Cancer care
Children and young person's health and care
Community services
End of life care
GP surgeries and primary care
Healthy Lifestyle Training
Intermediate care
Long term conditions (diabetes, breathing illnesses and heart disease)
Maternity and new born care
Mental Health
Older People's Services
Primary Care
Sefton QIPP
Support for carers
Urgent Care eg services and treatments which are carried out in an emergency
Young People
How are you connected with the CCG?
Ainsdale and Birkdale
Care Home managers
Carer
Chair
Chief Officer
Councillor or MP
Deputies
Local Authority
Media or Communications
Member of a PPG - a Practice Patient Group
Orgs with Personal Emails
Other Provider
Partners
Patient or member of the public
PPG development group
Sefton Transformation Board
Stakeholders
Voluntary, Community or Faith Organistion
Work in General Practice
Work in the NHS eg hospital trust, ambulance trust, mental health trust, community services
Young person
How did you hear about the CCG?
Face-to-face recruitment
Website
Mail out
Event
Other
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
Ethnic Origin
Religion/Belief
Sexual Orientation
Languages
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?
How are you connected with the CCG?
How did you hear about the CCG?
4. Finish
*
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