I Would Like To Become A Member Of The Trust *
Yes  No 

Personal Details

Mr  Mrs  Ms  Miss  Dr 

Surname *

First Name *

Address *
 
 

Postcode *

Telephone Number *

Email *

Area In Which I Live:

Harlow
Epping Forest
Broxbourne
East Hertfordshire
Uttlesford

Are You Or Have You Been?

A patient at PAH
A carer of someone who is a patient
A volunteer at PAH

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

Find out more about the work of the Trust
Take Part in consultation of the Trusts plan
Consider standing for election as a Governor
Advocate for the Trust within the community

How should we contact you? (Tick as many boxes as you wish)

Email
Post
Telephone

Are you a member of an organisation or local group which would like more information about the work of the Trust?

Yes  No 

If yes, then name of the organisation or group

Would you mind telling us a little about yourself?

Male  Female 

Date of birth Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

I wish to be included on the public register of members
Yes  No 

What is your ethnic group?

White

Asian or Asian British

Black or Black British

Mixed

Chinese or Far Eastern origin

Any other Ethnic group

If you consider yourself to have a disability, please give details

A Sensory Disability
A Physical Disability
A Mental Health Problem
A Learning Disability
Another Special Need

Declaration

I confirm that I am 14 years or over * Yes  No