Involvement Scheme and membership form

* Fields are required

How much involvement do you want in the Trust? *

Involvement Scheme member - you will be invited to shape services going forward in our Trust.

Involvement Scheme and Foundation Trust member - in addition to the advantages of being part of the Involvement Scheme, you will receive regular updates about all services across the Trust.


Your name *



Your date of birth *



Your telephone number *



Your address (including postcode): *



Your email address



Do you have a long-term illness, health condition or disability? *



If you have answered yes, please indicate your disability and any special needs you have



Your ethinicity *



Your sexual orientation *



Your religion *



Level of engagement *

Active

For example, receiving regular updates, invitations to workshops and events, information about being a Governor to sit on our Council of Governors and comment on services and plans.

Informed
For example, taking part in surveys and commenting on services and plans.

Emergency contact details *








Declaration

As part of providing you with direct care, the Trust may have to share your information with other partner organisations. To find out more information about this, please refer to our Privacy Policy.

By clicking submit, I agree to the Trust contacting me using the details given above. I understand that the Trust will:
  • securely store the information relating to my referral (and subsequent care, where applicable) in paper and/or electronic format
  • keep the records for as long as required in the Records Management Code of Practice for Health and Social Care 2016 (or for longer if it is appropriate)
  • confidentially destroy records when necessary

 
Thank you. Your form has been received and you will be contacted as soon as possible.