Public Participation Group

Public Participation Group – Expression of interest form

Please share which group you are interested in joining(Required)

Your Voice

INVOLVE (13-19)

Name:(Required)

First Last

Age:(Required)

Gender:(Required)

If 'Other' please write below:

Is your gender the same as assigned at birth?(Required)

Mobile:(Required)

Email:(Required)

Address:(Required)

Street Address Address Line 2 City Postal Code

School/College:(Required)

How would you describe your sexual orientation?(Required)

Religion:(Required)

National (NHS) Ethnicity Codes:(Required)

Please Specify:(Required)

If 'Other' please write below:(Required)

Do you consider yourself to have a disability? Please let us know if you require any reasonable adjustments:(Required)

How did you hear about the Participation Groups?(Required)

Additional consent

I am happy for my photo to be used within service/media promotion and can be used on social media

I am happy to be added to a WhatsApp group (INVOLVE group only)

I am happy for my anonymised comments to be used as learning across the Trust

I am happy to be added to an email distribution list

Signed:(Required)

Date(Required)

Signed:(Required)

Date(Required)