Page 28 - Community Health magazine - issue 38

More about you
Sign up to be a member of KCHFT We ask for this information so we
can be sure our membership is
representative of the communities we
We will communicate with you by email, which saves the NHS money, however if serve. We would be grateful if you
you would like to be contacted in a different way, please let us know. would complete this section.
Your information will only be used to contact you regarding your membership and Date of birth:
held in accordance with the General Data Protection Regulation (GDPR). Everything (This is required as you must be 14-years
or older to be a member)
we ask for is used to make sure we stay in touch with you how you want us to and
that our membership is representative of the communities we care for. / /
(DD/MM/YYYY)
What is your ethnicity?
White British
Your contact details (please print in block capitals)
White Irish
White Gypsy or Irish traveller
Title .............................. First name .............................................................. White other (please state)

Last name ..................................................................................................... ..................................................................
Asian British
Address ........................................................................................................
Asian Indian
..................................................................................................................... Asian Bangladeshi
Asian Pakistani
............................................................. Postcode ........................................ Asian Chinese
Home phone number .................................................................................... Asian other (please state)
..................................................................
Mobile phone number ..................................................................................
Black British
Email address ................................................................................................ Black African
Black Caribbean
Black other (please state)
Tell us about you ..................................................................
Please tell us if you need any communication support, for example a British Sign Mixed other (please state)
Language interpreter. ..................................................................
............................................................................................................................. Other ethnic group (please state)
Please tell us if you need written information in another format, for example ..................................................................
large print, another language or easy read. Prefer not to say
............................................................................................................................. What is your gender?
Please tell us if you have a disability or long-term health condition:
............................................................................................................................. Male
Female
Prefer not to say Transgender
Other (please state)
..................................................................
How would you like to be involved? (please tick all that apply) Prefer not to say
Receive information from us about our services and our charity, i care If you do not wish to be listed on
Receive invitations to events and working groups the public register of members
please tick here.
Respond to surveys or comment on leaflets If you need this leaflet in an alternative
Receive information about employment opportunities format, please phone the Communications
Become a volunteer Team on 0300 790 0506 or email
kchft.comms@nhs.net

*
Please fill this in, pop it into an envelope and post it to:
FREEPOST RSCK-GRCK-YBER, Communications, Trinity House,
110-120 Upper Pemberton, Eureka Park, Ashford, Kent TN25 4AZ
*You don’t need a stamp

Find out more at www.kentcht.nhs.uk/member

28 www.kentcht.nhs.uk