Membership Application Form Membership Application Form Who can be a member? Membership is free and open to anyone over the age of 12 and living in Bedfordshire, Central Bedfordshire, Luton, City of London, Newham, Hackney, Tower Hamlets or living in any other areas of England. Public Members will include service users, carers and local residents. Your data is kept secure and will only be used to contact you about the Trust and will be stored in accordance with the Data Protection Act 1998. Name Title Title - None -MissMsMrMrsDrOtherOther… Enter other… First name Surname Address Address Address 2 City/Town ZIP/Postal Code Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Confirm email Confirm email Confirm email Phone number Gender Male Female Other Date of Birth Have you ever used Community Health Services? Yes No Prefer not to say If yes, please specify in what locality? Bedfordshire Hackney Newham Tower Hamlets Luton Have you ever used Mental Health Services? Yes No Prefer not to say If yes, please specify the locality? Bedfordshire Hackney Newham Tower Hamlets Luton Do you consider yourself to have a disability? Yes No Prefer not to say Are you a Carer for someone that has used Community Health Services? Yes No What services are you particularly interested in? Adult Mental Health Services Child & Adolescent Mental Health Services Older Peoples' Mental Health Services Learning Disability Services Forensic Mental Health Services Adult Community Health services Child Community Health services How would you like to be involved? Receive our quarterly newsletter Consider standing for election as a Trust Governor Volunteering Take part in consultation events People Participation (Service User Involvement) Attend the Annual Members Meeting and AGM Attend Members' Meetings East London NHS Foundation Trust relies on the many volunteers and service users who help us to keep improving the services we offer. The Trust’s dedicated People’s Participation Service works to put service users, families and carers at the heart of everything we do. We continually seek new members to take on important roles across all areas of the Trust, in order to help keep improving the services we offer. Please take a moment to consider whether you might be able to support the Trust in some way. (tick as many boxes as you wish) If you have ticked Volunteering , are you happy for your information to be handed over to the Trust’s Head of Volunteering, and for someone to get in contact with you? Yes No How did you hear about becoming a Member?