Please tell us a little more about you
Please select which type of membership you would like
Please provide the first line of your address
Please provide the second line of your address if applicable
Please provide the town or city of your address
Please provide your full postcode
Please provide the best number we can contact you on if you are happy to be contacted by telephone
Please select the description(s) you feel best describes you
Please select from the list which best describes your situation
Please select the description that best describes whether you have a disability or not
Please tick the age group you fall into
Please select your ethnicity to help us ensure we are including different communities within Coventry.
Please tell us a little about what areas interest you
Please select as many as you feel are relevant
Please tell us a little more about how you would like to be involved.
Please tick all that apply
We will send out information by email unless you need information in a different way
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.