Membership Application Form

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    Membership Application Form

    Fields marked * are required

    Title: *
    First Name: *
    Surname: *
    Email: *
    Telephone Number: *
    Address Line 1: *
    Address Line 2:
    Address Line 3:
    Postcode: *
    Gender: * Male: Female:
    D.O.B: * Day: Month: Year:
    (To become a member you need to be over the age of 14)
    Ethnicity: *
    White: British Irish
    Other White Background
    Mixed: White & Black Carribean White & Black African
    White & Asian Other Mixed Background
    Asian / Asian British: Indian Pakistani
    Bangladeshi Other Asian Background
    Black / Black British: African Carribean
    Other Black Background
    Other ethnic groups: Chinese Other Ethnic Group
    Not Stated: Not Declared


    Do you consider yourself to have a disability? *

    Yes: No:

    Do you consider yourself to have any other special requirements?
    e.g. mobility, hearing loop, sight aids, interpreter?


    Your Areas of Interest?

    Children and families - Includes accident prevention service, children's centres, contraception and sexual health service, school nursing, vaccination and immunisation services

    Community services - Includes community matrons, continence service, dentistry, dermatology, district nurses, learning disabilities, musculoskeletal service, occupational therapy, physiotherapy, podiatry, speech and language therapy, wound care

    Healthy living - Includes health promotion, healthy eating services, stop smoking service, weight management team

    Long term conditions - Includes cardiorespiratory services, diabetes, dementia care, lymphoedema, pulmonary rehabilitation, rheumatology

    Mental health - Includes child and adolescent mental health service, community mental health teams, crisis teams, early intervention service, eating disorder service, mental health inpatient services, social inclusion service, traumatic stress service

    Specialist services - Includes acquired brain injury service, harm reduction service, prison health service, secure inpatient services, substance misuse service


    As a member, what would you be interested in?

    Attending meetings & events
    Becoming a volunteer
    Participating in elections
    Standing as a Governor
    Service User and Carer involvement opportunities
    Participating in questionnaires, targeted surveys or focus groups


    Would you be interested in standing for election to the Council of Governors? *

    Yes: No: