Individual Membership Form :: Healthwatch Stockton-on-Tees

Name *

Address *

Postcode *

Telephone

Mobile

E-mail *

Please tell us about your area of interest or expertise you have in health and/ or social care locally *

How did you hear about Healthwatch? *

Promotion and Press

Yes

No

From time to time PCP will use photographs and film footage to record and promote its projects and services, on posters, leaflets, reports, website, social media and in press releases. I am happy to appear in promotional materials

Age range *

Date of Birth

Day

Month

Year

Gender

Employment status

Do you have caring responsibilities?

Yes

No

Do you consider yourself to have a disability as defined by the Disability Discrimination Act?

The Disability Discrimination Act (DDA) defines a disabled person as "someone who has a physical or mental impairment that has a substantial and long-term adverse effect on their ability to carry out normal day to day activities."

If you are disabled, please tick the impairments that apply to you:

Have you or a close member of your family ever served in the UK Armed Forces? *

Have you or a close member of your family ever served in the UK Armed Forces?

Are you part of the LGBT community? (Lesbian, Gay, Bisexual and Transgender)

Yes

No

Ethnic origin

Religious belief

I have understood and agree to the confidentiality disclaimer below *

Yes

Confidentiality disclaimer:PCP will treat the information you give confidentially, under the principles of The Data Protection Act 1998 and The Freedom of Information Act 2000. We will share information with our external funders and evaluators only where necessary for monitoring and evaluation purposes. We operate an 'open file' policy. Should you wish to view the personal information the organisation holds, please speak to a member of staff.

Individual Membership Form

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