East London NHS Foundation Trust : Membership_Application

Fields marked with * are mandatory.

Who can be a member?

To be a public member, you must live in the areas that we serve: the City of London, Hackney, Newham and Tower Hamlets or any other London Borough. Public Members will include service users, carers and local residents and the minimum age to become a member is 12.

First Name *

Last Name *

Date of birth *

Day/Month/Year

Title *

Mr
Miss

Mrs
Other

Gender *

Male
Other

Female

Address *

Postcode *

Mobile

Telephone

How would you prefer to be contacted?

Email
Phone

Post

Your ethnic background

White

British
Other White Background

Irish

Black or Black British

Caribbean
Other Black background

African

Asian or Asian British

Indian
Bangladeshi

Pakistani
Other Asian

Mixed

White & Black Caribbean
White & Asian

White & Black African

Other Ethnic Group

Chinese

Any other ethnic group

Have you ever used Mental Health Services?

Yes
Prefer not to state

Have you ever used Community Health Newham Services?

Yes
Prefer not to state

Are you a Carer for someone that has used Mental Health Services?

Yes
Prefer not to state

Are you a Carer for someone that has used Community Health Newham Services?

Yes

Do you consider yourself to have a disability:

Yes
Prefer not to state

What services are you particularly interested in? (tick as many as you wish)

Mental Health Services

Adult Mental Health Services
Child & adolescent mental health services
Learning disability services

Older peoples' mental health services
Forensic mental health services

Community Health Newham Services

Services for adults
Stroke
Diabetes

Services for children
Physiotherapy

Other (please give details)

How would you like to be involved? (tick as many boxes as you wish)

Receive the quarterly newsletter
Consider standing for election as a Council Governor
Volunteering

Take part in consultation and other events
Service User Involvement

How did you hear about becoming a Member?

Your data is kept secure and will only be used to contact you about the Trust and will be stored in accordance with the Data Protection Act 1988.

Signed

Date:

Day/Month/Year

If you wish, you may return this form in an envelope addressed to: FREEPOST RLSH-BBHX_ZRRU, Membership Office, East London NHS Foundation Trust, East One, 22 Commercial Street, London, E1 6LP (NO STAMP REQUIRED)

Captcha validation.
Please type in the security number shown to the right. *

This is an anti-spam measure to prevent automated submissions by asking you to confirm a random number. Humans can read this numbers shown, but computer programs cannot.

Membership Application Form