Membership

* Mandatory

1. Your details

Firstname *
Surname *
Address *
 
Postcode *
Daytime Tel No
Email *

How would you like us to contact you? *

 Email     Post     Phone

2. About you

We want our membership to represent all the groups and communities in Sheffield. To help us achieve this, we would like to know the following information about our members:
Gender * Male     Female 
Date of Birth *


Where did you hear about becoming a member? *

3. Ethnicity *

White British Yemeni
White Irish Indian
White Other Pakistani
Mixed: White/Black Caribbean Bangladeshi
Mixed: White/Black African Chinese
Mixed: Other Vietnemese
Black Caribbean Asian Other
Black African Other
Somali  
Black Other Prefer not to say

4. About your membership

I would like to be a member in the following group *
 Public (Must live in Sheffield)
 Service User (Must have used the Trust's services in the last 5 yrs)
 Carers (Must have cared for someone using the Trust's services in the last 5 yrs)
 Young Service User/Carer (As Service User or Carer & must be under 35 yrs)

If you are a service user or main carer which service(s) do you use?
 Learning disabilities
 Adult mental health (Under 65 years)
 Older people's mental health (Under 65 years)
 Substance misuse
 Other

How much would you like to be involved? *
 Just receive regular magazine
 Attend Members' events
 Become involved in a working group
 Become a governor
 I may be interested in becoming a governor, but would like to know more - please contact me

Would you also like to be a member of Sheffield Teaching Hospitals NHS FT and/or Sheffield Children's NHS FT?
 Sheffield Teaching Hospitals NHS FT
 Sheffield Children's NHS FT

If you would like to be actively involved, do you have any particular areas of interest?
Quality and standards Developing Services
Inpatient care Psychological Services
Dementia Care Community Services
Medicines Patient information
Women's Mental Health Faith and spirituality
Carers' needs and support Appointing staff and training
Employment services for service users
Needs of minority communities

5. For your protection

Your personal details will be stored on our membership database in accordance with the Data Protection Act and will not be shared with any other organisation.

Foundation Trusts are required to publish and make public a register of members. If you do not wish your name to appear on the public register please tick the box