Individual Membership Registration Form
Thank you for taking the time to register your interest in Healthwatch. By completing
this form you are asking us to keep you informed about our activities. We hope that you
will choose to get more involved in things which are of particular interest to you but the
extent of your involvement is entirely up to you.
Contact details
Name
Address
Postcode
Telephone
Mobile
Email
Please tell us about any particular areas of interest or expertise you have in health
and/or social care locally?
How did you hear about Healthwatch?
Word of mouth
Online
Other



Health professional

Leaflet/poster
Event

Local press
please state ________________________

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Equality & Diversity monitoring
We want to make sure that Healthwatch represents everyone living and working in your
area. By answering these questions you will help us to understand how well we are
representing your community. You do not have to answer all of the questions if you
prefer not to.
Please tick the relevant boxes:
Male 
Female 
Date of Birth:
Ethnic origin
White
Black/Black British


White other
Asian/Asian British
 Chinese
 Other


Benefit Claimant
 Seeking employment
Otherwise unemployed  Prefer not to say


Employment status
Employed Full/Part time
Retired

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Disability
The Disability Discrimination Act (DDA) defines a disabled person as “someone who has a
physical or mental impairment that has a substantial and long-term adverse effect on
their ability to carry out normal day to day activities.”
Do you consider yourself to have a disability as defined by the Disability
Discrimination Act?
Yes 
No 
If yes, please tick the impairments that apply to you:
Physical Impairment
Sensory impairment


Mental health condition
Learning disability


Other
Prefer not to say

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Caring responsibilities
Do you care for a friend, relative or partner?
Yes 
No 
Have you or a close member of your family ever served in the UK Armed Forces?
Yes 
No 
Prefer not to say 
The information on this form will be stored and processed using a computerised
database for the purposes of administering Healthwatch Redcar and Cleveland, run by
the Pioneering Care Partnership (PCP), Carers Way, Newton Aycliffe, DL5 4SF. We may
contact you in the future to check the accuracy of this information. However, during
this period you are reminded that PCP can only keep information about you up to date if
you inform us of any changes.
Confidentiality disclaimer
PCP will treat the information you give confidentially, under the principles of The Data
Protection Act 1998 and The Freedom of Information Act 2000. We will share
information with our external funders and evaluators only where necessary for
monitoring and evaluation purposes. We operate an ‘open file’ policy should you wish
to view the personal information the organisation holds please speak to a member of
staff.
Please sign below to say that you have read and understood this statement, and
agree to PCP using the information you have given on this form.
I have understood and agree to the above confidentiality disclaimer:
Signed:_______________________
Date:______________________
If an email address has been provided, we will assume that this is the method via which you want to receive
updates.
Please return this form to:
Freepost RTCZ-YTAY-RYYA
Healthwatch, Catalyst House, 27 Yarm Road, TS18 3NJ
[email protected]