Join us

About you

Please tell us a little more about you

First name *

Please provide your first names

Family name *

Please provide your family or surname

Type of membership *

As an individual

As a voluntary or community group representative

Please select which type of membership you would like

Please name the group

Please name the voluntary or community group you are representing.

Email *

Please provide an email address we can contact you on

Address line 1 *

Please provide the first line of your address

Address line 2

Please provide the second line of your address if applicable

Town / City *

Please provide the town or city of your address

Postcode *

Please provide your full postcode

Telephone number

Please provide the best number we can contact you on if you are happy to be contacted by telephone

Gender *

Please select the description(s) you feel best describes you

Please describe your gender

Please tell us how you describe yourself

Are you a family / informal carer? *

Please select from the list which best describes your situation

Do you consider yourself to be disabled? *

Please select the description that best describes whether you have a disability or not

Please select your age group *

Please tick the age group you fall into

Ethinicity *

Please select your ethnicity to help us ensure we are including different communities within Coventry.

If other please describe your ethnicity

Please describe your ethnicity

Interests

Please tell us a little about what areas interest you

Please select all areas that interest you

Please select as many as you feel are relevant

Please describe what other areas interest you

Please describe all other areas of health or social care that are of interest to you

Your involvement

Please tell us a little more about how you would like to be involved.

How would you like to be involved?

Receive information and the option to be involved in surveys and meetings or events

Find out more about volunteering

Please tick all that apply

Communications

We will send out information by email unless you need information in a different way

Do you have any communication needs?

Please tell us about any needs you have to make information more accessible - for example do you require information by post or in large print?

How we use your information

We will not pass on your information or data to third parties outside of Healthwatch Coventry without your permission. You can ask Healthwatch to delete your membership information at any time. Find out more about how we safeguard and use information here.

If Voluntary Action Coventry stops running Healthwatch Coventry we will write to you with your options before passing your contact details to the new organisation.

I confirm that the information given on this form is true and I agree to my information being held on the databases and paper files for the purposes of Healthwatch Coventry.

Consent *

I confirm that the information given is true and agree to it being held by Healthwatch Coventry.