Personal Details

Surname/Family Name ^*

First Name ^*

Title ^*

Address ^*

Postcode ^*

Home Telephone ^*

Please enter N/A if you do not have one or do not wish to provide this information.

Mobile Telephone ^*

Please enter N/A if you do not have one or do not wish to provide this information.

Email Address

Preferred method of contact (please select one) ^*

Email Text Post

Please ensure you have filled out the relevant field above for your chosen option

Please let us know what your areas of interest are in relation to East Kent Hospitals services.

Is there anything else you would like us to know?

East Kent Hospitals is an NHS Foundation Trust. Members of the public can apply to be a member. Membership is free. Would you like to become a trust member?

Yes No

Please state your usual availability.

Communication and access needs

Please tell us if you have any communication or access needs, so that we can enable you to participate. This could include information in large print, wheelchair access for meetings, a hearing loop or any other adjustment:

Your communication and access needs (if applicable)

References

Please provide two references from people who have known you for at least three years.

Please ensure that these people have agreed to their contact details being shared.

Referee 1

Surname/Family Name

Title

Address

Postcode

Telephone

Email

Relationship/Profession (how does this person know you)

Referee 2

Surname/Family Name

Title

Address

Postcode

Telephone

Email

Relationship/Profession (how does this person know you)

Declaration

By completing and returning this form, you are agreeing to have your details stored for this period of time. You are welcome to contact the team and terminate your application or information held at any time.

I confirm that the information on this form is true and complete

I understand that the details entered in this part of the form will be held by the Patient Voice and Involvement team for up to three years.

Equality Monitoring Information

The information collected will only be used for monitoring purposes in an anonymised format and will help the Trust analyse the profile and make up our volunteers to support our equal opportunities policy.

We recognise and actively promote the benefits of a diverse range of volunteers and are committed to treating all volunteers with dignity and respect regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and sexual orientation.

Age

Gender

Male

Female

Non-binary

I do not wish to disclose this

Is your gender identity the same as the sex you were assigned at birth?

Yes

No

I do not wish to disclose

Ethnic Origin

I would describe my ethnic origin as:

Asian or Asian British

Bangladeshi

Indian

Pakistani

Chinese

Any other Asian background

Black or Black British, Caribbean or African

African

Caribbean

Any other Black, Black British or Caribbean background

Mixed or Multiple Ethnic Groups

White & Asian

White & Black African

White & Black Caribbean

Any other mixed or multiple ethnic background

Other Ethnic Group

Arab

Any other ethnic group

White

English, Welsh, Scottish, Northern Irish or British

Irish

Gypsy or Irish Traveller

Roma

Any other White background

I do not wish to disclose my Ethnic Origin

Disability

Do you consider yourself to have a disability or long-term health condition?

Yes (please complete the section below)

No

I do not wish to disclose this information

Please state the type of disability / impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

Physical Impairment

Learning Disability/Difficulty

Sensory Impairment (hearing / sight)

Long-Term Health Condition

Neurodiversity (Autism, AH, ADHD, Dyslexia, Dyspraxia)

Lived experience of mental health

Other

Sexual Orientation

Please select which sexual orientation applies to you:

Heterosexual or straight

Gay or lesbian

Bisexual

Other sexual orientation not listed (please state)

I do not wish to disclose

If Other, please state

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